6.3 Virginia State Health Programs

Virginia Medicaid and Expansion

Medicaid is the joint federal-state program for low-income residents. The single most-tested Virginia fact: Virginia IS a Medicaid expansion state, effective January 1, 2019. Expansion covers adults ages 19–64 with household income up to 138% of the Federal Poverty Level (FPL).

Exam Tip: If asked whether Virginia expanded Medicaid, the answer is yes — in 2019 (not 2014). The expansion threshold is 138% FPL. Both numbers are tested.

Virginia's Health Insurance Marketplace

For its first ACA years Virginia used the federal HealthCare.gov platform. That changed: Virginia stood up its own state-based marketplace — Virginia's Insurance Marketplace (branded "Marketplace Virginia") — which began operating its own enrollment platform for plan year 2024. The State Corporation Commission's Bureau of Insurance oversees it.

If a legacy exam item still says "federal partnership marketplace using HealthCare.gov," recognize that Virginia has since transitioned to a full state-based exchange — the most current and correct description.

Subsidy Mechanics

Premium tax credits scale inversely with income: lower-income enrollees get larger credits. Cost-sharing reductions lower deductibles and copays but are available only on Silver plans. A purchaser at, say, 200% FPL who picks Silver gets both a premium credit and reduced cost sharing; the same person choosing Bronze keeps the premium credit but loses the cost-sharing reduction. This Silver-only rule is a favorite distractor.

Cardinal Care and Managed Care

Virginia rebranded its Medicaid and FAMIS delivery system as Cardinal Care, the umbrella name for the state's managed-care program. Most Medicaid and FAMIS members enroll with a managed care organization (MCO) that coordinates their care, rather than receiving services on a fee-for-service basis. For the exam, the takeaways are simpler than the branding: Virginia covers low-income adults to 138% FPL, children through FAMIS, and delivers most benefits through managed care. The Department of Medical Assistance Services (DMAS) administers the program at the state level.

FAMIS — Virginia's CHIP

FAMIS (Family Access to Medical Insurance Security) is Virginia's Children's Health Insurance Program (CHIP). It covers children whose family income is above Medicaid limits, up to roughly 200% FPL.

FAMIS benefits are comprehensive — medical, dental, vision, and behavioral health — at low or no premium. A related program, FAMIS Prenatal / FAMIS MOMS, covers pregnant individuals for prenatal care, delivery, and postpartum services up to a similar income ceiling. Tie "CHIP" → "FAMIS" → "children up to ~200% FPL."

Virginia Life, Accident and Sickness Insurance Guaranty Association

Governed by Title 38.2, Chapter 17, the Guaranty Association pays covered claims when a licensed member insurer becomes insolvent. It is funded by assessments on member insurers — not by the state. Statutory maximums per insured life, per insolvent insurer:

A critical cap: total benefits for any one life generally cannot exceed $350,000 across life, annuity, and most A&S lines combined — except a health benefit plan, which has its own $500,000 ceiling. So a policyholder with both life and annuity coverage from the same insolvent insurer is capped at $350,000, not the sum of the individual limits.

What Is NOT Covered

• Policies from unlicensed / non-member insurers (surplus lines)
• Self-funded (ERISA) employer plans
• The investment/separate-account portion of variable products
• Government programs (Medicare, Medicaid)
• Amounts above the statutory caps

The Advertising Prohibition

Exam Tip: A producer may never use Guaranty Association coverage as a selling point or inducement. Telling a prospect "your policy is guaranteed by the state association" is a prohibited practice under § 38.2-1700-series rules. This is one of the most frequently tested ethics items — the existence of the association must not be advertised to sell a policy.

The rationale: advertising the safety net could lull consumers into ignoring an insurer's financial strength and could encourage carriers to take on excessive risk. The prohibition applies to all producers and to insurer marketing materials alike. A required notice describing the association may be delivered with a policy after issue, but that notice is a consumer disclosure — it can never function as a sales pitch or a guarantee that the buyer's specific policy is fully protected.