Answers to common questions

Medicaid is a program that provides health care for millions of Americans. It covers low-income workers and:

• Children
• Families
• Seniors 
• Pregnant women
• People with disabilities
• People receiving long-term services and supports

If you qualify, you can get coverage for things like:

• Preventive care
• Vision care
• Dental care
• Medications
• Disease management
• Mental and behavioral health

In Virginia, there are different plan options:

Cardinal Care

FAMIS

Medicare and Medicaid dual plans

Find out if you qualify

Before you can get coverage, be sure you qualify for Medicaid programs.

After you qualify, you can choose Aetna Better Health as your health plan.

You can also read the answers to 10 common questions about qualifying for Medicaid.

Learn more about how to enroll

To keep your coverage, you must renew every year.

Learn how to renew

We want you to be happy with the care you get. So if you’re ever unhappy with your health plan or a provider, you can file a grievance. Or you can file an appeal if we deny, delay or change a service. If you don’t agree with the decision on your appeal, you can ask for a state fair hearing.

Grievances and appeals

Tell us. You have the right to report anyone you believe is committing fraud or abuse.

Fraud and abuse

You’ll find your health plan summary and benefits info in your member handbook or on your Member Portal or Aetna Better Health app.

Learn more about your Member Portal and app

We’re here for you 24 hours a day, 7 days a week. Just visit our contact us page to find helplines for your plan. Or log in to your Member Portal or Aetna Better Health app.

Learn more about your Member Portal and app

You have some options if you lose your member ID card. First, log in to your Member Portal or Aetna Better Health app. There, you can:

• Ask us to mail you a new ID card
• Find the electronic version of your ID card — as long as you have your smartphone, you’ll always have your ID card with you for health care visits

Or just contact us.

Learn more about your Member Portal and app

To keep your benefits, you’ll want to make sure that any info we have from you stays current. Your info may include:

• Your address 
• Your phone number 
• Your job 
• Your income 
• People living in your household 

Report a change in your info

If your info changes, you’ll need to notify Cover Virginia within 10 days of it happening.

Learn how to report a change

Your PCP is a medical provider who will manage your health care. They’re the doctor, nurse, physician assistant or clinic that provides your main health care. They’ll help you get all the covered services you need.

Find a provider

You can change your PCP through your Member Portal or Aetna Better Health app. You can also contact us for help. 

More about choosing a PCP

More about your Member Portal and app

Your ID card will have your PCP’s name and phone number. You can also find this info on your Member Portal or Aetna Better Health app.

Learn more about your Member Portal and app

Specialists are providers who treat specific conditions. Your PCP might refer you to a specialist in our network. Or they may recommend you see one. Need help finding a specialist? Just contact us.

Find a specialist

You can find providers for the health care services you need. 

Find a provider

Whether it’s day or night, your PCP or on-call provider can tell you what to do. If they’re not in the office, leave a message. They’ll return your call. Your provider must see you within 24 hours if you need urgent care.

If you're having an emergency, call 911 or go to the closest hospital.

You’ll only need emergency care if you think your health is in serious danger. Emergencies may include:

• Severe pain
• Serious injury
• Sudden illness
• Illness that is quickly getting much worse
• Heavy bleeding that doesn’t stop, especially if you’re pregnant

If it’s not an emergency, but you need medical advice, contact us. Then, choose the option for the 24-Hour Nurse Line. A nurse can help you decide if you need to go to the ER or urgent care.

Check out some of these articles to learn more about getting the right care at the right time:

• Is it an emergency?

• Where to go for quick medical care

Find a hospital

If you have no way to get to the hospital during an emergency, call 911. We cover ambulance rides on the ground in a medical emergency. 

Need a ride to your doctor visits? You can get help with rides to medical services we cover. We cover rides for your nonemergency medical needs. You can get a ride for visits to your:

• Health care provider 
• Dental or vision provider
• Mental or behavioral health care provider 
• Pharmacy

Rides

If you’re away from home and have an emergency, go to the closest hospital or call 911. The hospital doesn’t have to be in our network for coverage and care.

You can use the provider search tool to find a hospital. Or you can contact us for help.

Find a hospital

Pregnant women need special care. You’ll want to see a provider within three weeks of a positive pregnancy test (home or lab). We can help with pregnancy care. Just contact us as soon as you can.

You can also visit our health and wellness library to learn more about pregnancy, women’s health and other topics to help keep you healthy.

Pregnancy care

You’ll want to make sure your baby has medical coverage. If you don’t have insurance when your baby is born, enroll them into Medicaid benefits. 

Learn how to enroll your baby

If you have questions or need help, just contact us.

When you have a condition, you’ll work with your health care provider to set up a treatment plan. The plan will likely include certain steps, like:

• Taking medication
• Making lifestyle changes, like eating and exercise
• Finding emotional support

Some conditions can benefit from disease management, like:

• Asthma 
• Chronic obstructive pulmonary disease (COPD) 
• Diabetes 
• Congestive heart failure (CHF)
• Coronary artery disease (CAD) 
• Depression

Do you have one of these conditions? If yes, you may be able to get help from a care manager. You can learn more on our page about disease management. Or contact us for help.

Disease management

A formulary is a list of covered medications. The list may come from your state or health plan. These medications treat a variety of conditions. You can learn more on our pharmacy benefits page.

Pharmacy benefits

We work with a group of doctors and pharmacists to help us make these decisions. This group is known as the Pharmacy and Therapeutics (P & T) Committee. First, we get input from many doctors. Next, our medical directors and pharmacists get input from our other health plans. Then, we choose the right medications for the formulary. Often, two medications are equally safe and effective. They can have differences in their known benefits. 

After a review, the P & T committee may add medications to the list. New medications may be added every year. We also try to remove them once a year. Some medications are a benefit exclusion under the Medicaid benefit policy.

You can ask your provider to:

• Give you a similar medication that is preferred on the list
• Get prior authorization (PA) to cover this medication if they think it’s necessary to treat your medical condition

Doctors try to choose medications on the formulary. Sometimes they’ll choose medications not on the formulary. Your doctor may have forgotten which medications are on your plan list. 

Oftentimes, doctors may choose new or other medications because:

• They met with a drug company representative
• They saw an advertisement
• They’ve used the medication in the past (even though other ones are on the list)

We make sure that the right medications are on the formulary. You can learn more on our pharmacy benefits page.

Pharmacy benefits

First, your provider will contact us. Then, our pharmacy staff will review the info your provider gave us. Finally, we’ll make a decision. 

Some health care services and supplies need approval before you can get them. We follow nationally recognized guidelines to make these decisions. Before providing a service, your provider must check the list. It may change from time to time. You can learn more about PA.

Note about pharmacy PA timelines: For urgent and non-urgent service requests, allow us at least 24 hours for a response.

Prior authorization

You don’t need a referral to see in-network providers for routine and preventive health care services.

You do need PA for some health care services and supplies before you get them. We use nationally recognized guidelines to make PA decisions about care your provider suggests.

Your provider must check to see if your service requires PA before they provide it. You can learn more about PA.

Prior authorization

We work with the state to set quantity limits for different reasons. Some medications have a maximum limit or dose for safety reasons. Our clinical staff sets the limits based on proven standards of care, such as the U.S. Food and Drug Administration (FDA) guidelines. In some cases, we make exceptions. Have your provider contact us. We’ll review the info from your provider and make a decision. You can learn more about pharmacy benefits.

Pharmacy benefits

These types of medications aren’t covered on the formulary: 

• Cosmetic
• Hair growth
• Weight gain
• Infertility or erectile dysfunction
• Experimental or investigational
• DESI (drug efficacy study implementation) drugs
• Drugs marketed by companies who do not take part in the Medicaid Drug Rebate Program

Staying active is one of the best things you can do for your health. It can:

• Give you more energy
• Help you feel better 
• Prevent some health problems that go along with aging

Some physical activity is better than none at all. But check with your doctor before you start — just to be sure it’s safe. Want to learn more about staying active? 

Learn more about exercise

You can learn more about health goals, info and coaching.

Health coaching

You’re not alone. During the COVID-19 pandemic, many people have felt more stress and anxiety than ever. They need more help than usual coping with everyday pressures. Things like job loss, child care issues and other challenges are very real.

Did you know that stress can affect your health? It’s common during times of stress to pick up some unhealthy habits. Don’t be too hard on yourself. It’s not always easy, but you can learn ways to:

• Eat healthy
• Exercise regularly
• Start other healthy habits 

Learn more about healthy habits:

• Healthy living resources
• 4 ways to take care of physical and mental well-being during unsettled times
• Staying mentally healthy in tough times

Your PCP can give you more personal help and treatment. Be sure you know who your PCP is and make an appointment today. Your ID card will have your PCP’s name and phone number. Or you can find this info on your Member Portal or Aetna Better Health app.

Learn more about your Member Portal and app

It may not be easy, but you can stop using nicotine — whether it’s smoking, vaping, chewing or another form. Let’s quit together.

Find more support

You can also learn more about quitting from the:

• American Cancer Society’s guide to quitting smoking
• Great American Smokeout® event
• Centers for Disease Control and Prevention at 1-800-QUIT-NOW (1-800-784-8669)

Your PCP can give you more personal help and treatment. Be sure you know who your PCP is and make an appointment today. Your ID card will have your PCP’s name and phone number. You can also find this info on your Member Portal or Aetna Better Health app.

Learn more about your Member Portal and app