Health Insurance Marketplace in Virgina
If you live in Virginia, you’ll use this website, HealthCare.gov, to apply for coverage, compare plans, and enroll.
Spanish language speakers can contact cuidadodesalud.gov.
Choosing the Right Health Insurance Plan
There are 5 categories of Marketplace insurance plans: Bronze, Silver, Gold, Platinum, and Catastrophic.
Plans range from bare bones “bronze” plans which cover 60% of pocket medical costs to “platinum” plans which have greater coverage but come with higher premiums. In general higher premiums mean lower out-of-pocket costs and a wider insurer network of doctors and hospitals.The plans are as listed below:
NOTE: All cost sharing is of out of pocket costs. Please see ObamaCare health benefits for services that are covered at no out of pocket charge on all plans. The maximum out-of-pocket costs for any Marketplace plan for 2014 are $6,350 for an individual plan and $12,700 for a family plan.
Bronze Plan: The bronze plan is the lowest cost plan available. It has the lowest premiums and in exchange has the lowest actuarial value. The actuarial value of a bronze plan is 60%. This means that 60% of medical costs are paid for by the insurance company, leaving the other 40% to be paid by you.
Silver Plan: The Silver plan is the second lowest cost plan, it has an actuarial value of 70%. This means that 70% of medical costs are paid for by the insurance company, leaving the other 30% to be paid by you. The Silver plan is the standard choice for most reasonably healthy families who historically use medical services.
Gold Plan: The Gold plan is the second most expensive plan, it has an actuarial value of 80%. This means that 80% of medical costs are paid for by the insurance company, leaving the other 20% to be paid by you.
Platinum Plan: The Platinum plan is the plan with the highest premiums offered on the insurance exchange. The Platinum plan as an actuarial value of 90%. This means that 90% of medical costs are paid for by the insurance company, leaving the other 10% to be paid by you. This plan is suggested to those with high incomes and those in poor health. Although coverage is more expensive up front the 90% coverage of costs will help those who use medical services frequently.
Catastrophic plans – which have very high deductibles and essentially provide protection from worst-case scenarios, like a serious accident or extended illness — are available to people under 30 years old and to people who have hardship exemptions from the fee that most people without health coverage must pay.
Virginia has not chosen to expand its Medicaid program at this time. Read “What if my state isn’t expanding Medicaid?” to learn more. You can find out whether you qualify for Medicaid under Virginia’s current rules 2 ways: Contact your state Medicaid agency right now or fill out an application for coverage in the Health Insurance Marketplace.
Who can help you (the Navigators)
The Virginia Poverty Law Center (VPLC) is a non-profit organization that serves Virginia’s legal aid system by providing advocacy, training, and litigation support on civil justice issues that affect low-income Virginians based in Richmond. It provides training and technical assistance to the legal aid community and others and works on health care issues with a wide range of statewide organization and partners. It will be working with a statewide consortium of nine well-established legal services programs in the commonwealth.
For nearly 14 years, Advanced Patient Advocacy has partnered with health care providers and state and local governments in 21 states to provide services to communities to help educate and enroll uninsured consumers. Advanced Patient Advocacy will work with medical centers to identify uninsured individuals and provide education and assistance to help them make informed decisions about enrollment in the Marketplaces.
Who you can contact for more help
If you need more detailed analysis, identification of issues, solutions, and implementation of your health insurance plan please let us know with the form below and we’ll get right back to you.
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Accountable Care Organizations in Virginia
ACOs are profit-driven health innovators primarily serving Medicare patients who are financially rewarded by the government and private insurance companies for delivering medical services that lead to better health outcomes for less money.
- The Rector And Visitors Of The University Of Virginia VA – Health Care Innovation Award
- Carilion New River Valley Medical Center VA – Health Care Innovation Award
- George Washington University VA – Health Care Innovation Award
- University Of North Texas Health Science Center VA – Health Care Innovation Award
Health care facilities where Innovation Models are being tested
- St. Mary’s Hospital Richmond, VA – BPCI Initiative: Model 2
- Johnston Memorial Hospital Abingdon, VA – BPCI Initiative: Model 2
- Lynchburg General Hospital Lynchburg, VA – BPCI Initiative: Model 2
- Appalachian Community Transitions (ACTion) Project Cedar Bluff, VA – Community-based Care Transition Program
- Eastern Virginia Care Transitions Partnership Urbana, VA – Community-based Care Transition Program
- Clinch River Health Services Dungannon, VA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Meadowview Health Clinic Meadowview, VA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Tazewell Community Health North Tazewell, VA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Tri-Area Community Health Center at Ferrum Ferrum, VA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Vernon J. Harris East End CHC dba Capital Area Health Network Richmond, VA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- William A. Davis Clinic Saint Paul, VA – Federally Qualified Health Center Advanced Primary Care Practice Demonstration
- Virginia Commonwealth University Richmond, VA – Independence at Home Demonstration
- Grace Hines MBA Norfolk, VA – Innovation Advisors Program
- Len Nichols PhD Fairfax, VA – Innovation Advisors Program
- Colleen Kraft MD Roanoke, VA – Innovation Advisors Program
- NOVA Natural Birth Center Chantilly, VA – Strong Start for Mothers and Newborns Initiative
- Shenandoah Women’s HealthCare Shenandoah, VA – Strong Start for Mothers and Newborns Initiative
- Greater Prince William Community Center Woodbridge, VA – Strong Start for Mothers and Newborns Initiative
- The Richmond City Health Department Richmond, VA – Strong Start for Mothers and Newborns Initiative
- Complete Care Birthing Center Richmond, VA – Strong Start for Mothers and Newborns Initiative
- Monassas Midwifery Women’s Health Center Monassas, VA – Strong Start for Mothers and Newborns Initiative
- Virginia Commonwealth University Richmond, VA – Strong Start for Mothers and Newborns Initiative
The Insurance Exchange/Marketplace
What has been done, not been done, or left up to the federal government to do.
Establishing the Exchange in Virginia
On December 14, 2012, Governor Bob McDonnell (R) informed federal officials that Virginia would not continue to plan for a state-based health insurance exchange.1
Prior to the decision, Governor McDonnell had signed HB 2434 into law declaring the state’s intent to establish a state-based health insurance exchange.2 The legislation was based on a recommendation by the Virginia Health Reform Initiative Advisory Council, housed within the Virginia Department of Health and Human Resources.3 HB 2434 required the Governor to submit recommendations regarding establishment of an exchange in Virginia for consideration during the 2012 session of the General Assembly and prohibited qualified health insurance plans offered through the exchange from covering abortions, except in cases of rape, incest, or life endangerment of the pregnant woman.
On November 25, 2011, the Advisory Council’s exchange recommendations were submitted to the General Assembly by the Governor.4 The Council voted in favor of establishing a state-based exchange as a quasi-governmental agency with a governing board.5 However, Governor McDonnell opposed passing the additional legislation needed for the establishment of a state-based exchange until after the Supreme Court ruled on the Affordable Care Act (ACA) in late June 2012.6 Numerous bills to establish a state-run health insurance exchange were introduced in the Virginia Legislature in 2012; however, all were tabled for the next legislative session.7 In the absence of establishment legislation, the Advisory Council temporarily suspended its meetings.
Contracting with Plans: On February 14, 2013, Governor McDonnell sent a letter to the Center for Consumer Information and Insurance Oversight (CCIIO) announcing the state’s intent to perform plan management activities despite not having entered into a state-federal partnership exchange.8 On March 21, 2013 Governor McDonnell approved legislation authorizing the State Corporation Commission (SCC) to perform plan management functions, including collecting and analyzing information on plan rates, benefits, and cost-sharing and ensuring continued plan compliance. The SCC was also granted the authority to manage consumer complaints, provide technical assistance, and decertify issuers. The legislation authorizes the Virginia Department of Health to assist in plan management functions.9 Premium rates will vary based on family composition, age, tobacco use, and geographic area.10 Virginia will have 12 geographic rating areas, determined by the federal default mechanism.11
Consumer Assistance and Outreach: In April 2013, Governor McDonnell signed into law HB 2246 and SB 1261 to prohibit navigators from performing activities that would require an insurance agent license. Navigators must be selected in accordance with federal law and may not act as intermediaries between employers and insurers offering QHPs or dental plans through the Exchange. The SCC will monitor Navigator activities and submit findings to the Governor and the Senate and House Commerce and Labor Committees in November of 2014 and 2015.12
Information Technology (IT): Virginia is focusing on a significant Medicaid IT system upgrade and has received approval from the Centers for Medicare and Medicaid Services (CMS) for an enhanced federal match. In May 2012, the state released a Request for Proposals soliciting subcontractors to streamline eligibility and enrollment for all existing social service benefits, including Medicaid, TANF, and food stamps. State officials envision eventual interoperability between the upgraded system and an exchange.
Essential Health Benefits (EHB): The ACA requires that all individual and small-group plans sold in a state, including those offered through the Exchange, cover certain defined health benefits. States must decide whether to benchmark their EHB plan to one of ten plans operating in the state or default to the largest small-group plan in the state. Drawing input from multiple stakeholders and various analyses, the Advisory Council recommended in June 2012 that a subcommittee be established to consider Anthem, the state’s small-group PPO as the state’s benchmark plan. The subcommittee recommended Anthem as the EHB benchmark plan and the Children’s Health Insurance Program (CHIP) dental benefit plan (Smiles for Children) as the pediatric dental supplemental plan.13
In September 2010, the Virginia State Department of Medical Assistance Services received a federal Exchange Planning grant of $1 million. The state planned to submit a Level One Establishment grant application in June 2012; however, the Governor announced in a letter to the Legislature in July, he decided not to submit the application.14 In February 2013, Virginia received a $4.3 million Level One Establishment grant to support plan management functions, including hiring IT consultants and engaging stakeholders. In July 2013, Virginia received a second Level One Establishment grant for $1.2 million to fund the actuarial analysis needed to support the certification, decertification, and recertification of QHPs and stand-alone dental plans.15
Virginia, along with nine other states, received technical assistance from the Robert Wood Johnson Foundation through the State Health Reform Assistance Network; this assistance includes help with setting up health insurance exchanges, expanding Medicaid to newly eligible populations, streamlining eligibility and enrollment systems, instituting insurance market reforms and using data to drive decisions.16
Expansion of Medicaid
From 2014 to 2017, the federal government will pay for 100% of the difference between a state’s current Medicaid eligibility level and the ACA minimum. Federal contributions to the expansion will drop to 95% in 2017 and remain at 90% after 2020, according to the ACA.
As the ACA was originally written, states would lose all Medicaid funding if they refused to expand their program to the ACA minimum.
However, the Supreme Court in June 2012 ruled that the federal government could not withhold Medicaid funding for states that chose not to expand their programs. The decision effectively allowed state officials to opt out of the expansion, and some have said they will do just that.
Virgina legislature passed a Medicaid expansion measure but the governor has not included expansion in his budget.
On March 29, 2013, Virginia received approval from CCIIO to perform plan management activities. The federal government will retain control over all other Exchange functions.17
More information about the Advisory Council’s health insurance exchange activities can be found at: http://www.hhr.virginia.gov/Initiatives/HealthReform/index.cfm
- Governor McDonnell Letter to Secretary Sebelius. December 14, 2012.← Return to text
- HB2434. Virginia’s 2011 Health Benefit Exchange Act.← Return to text
- Report of the Virginia Health Reform Initiative Advisory Council. December 20, 2010.← Return to text
- Report Pursuant to House Bill 2434: Virginia Health Reform Initiative (VHRI) Advisory Council recommendations for a Health Benefit Exchange. Report of the Secretary of Health and Human Resources. November 25, 2011.← Return to text
- The Virginia Health Reform Initiative. Presentation to House Appropriations Committee. November 16, 2011.← Return to text
- Martz, Michael. ‘McDonnell: If health insurance mandate stands, Va. should run exchange.’ Richmond Times-Dispatch. December 9, 2011.← Return to text
- See: http://lis.virginia.gov/← Return to text
- Letter from Governor McDonnell to Gary Cohen. February 14, 2013.← Return to text
- SB 922 Health insurance; SCC< et al., to perform plan management functions, review of premium rates.← Return to text
- State Corporation Commission, Bureau of Insurance. Rules Governing Riling of Rates for Individual and Group Accident and Sickness Insurance. July 1, 2013.← Return to text
- Virginia Geographic Rating Areas Including State Specific Geographic Divisions. CCIIO.← Return to text
- Dise, Monty. EHB Subcommittee Report to the Virginia Health Reform Initiative Advisory Council. June 13, 2012.← Return to text
- Salasky, Prue. “Gov. McDonnell tells GA members no special session necessary on health care.” Dailypress. July 10, 2012.← Return to text
- Virginia Affordable Insurance Exchange Grants Awards List.← Return to text
- Robert Wood Johnson Foundation. ‘RWJF Seeks Coverage of 95 Percent of All Americans by 2020.’ May 6, 2011.← Return to text
- Letter from Gary Cohen to Governor McDonnell. March 29, 2013.← Return to text
Also of interest
Provided by the Henry J. Kaiser Family Foundation