Applications

Applying for health insurance

Application for Health Coverage & Help Paying Costs
[PDF] English | Spanish | Order online

Applying for more than two people

You may need to print more pages if you are applying for Medicaid, FAMIS or Plan First for more than two people in your household. Use the Additional Person Single Page Supplement. You cannot use this application by itself. You must also complete the Application for Health Coverage & Help Paying Costs. Then submit the Additional Person Single Page Supplement with your application. Order online

[PDF] Additional Person Single Page Supplement (English)
[PDF] Additional Person Single Page Supplement (Spanish)

Applying for Medicaid for adults over age 19 with disabilities, or who are 65 or older, or for anyone who needs long-term care

You must complete the ABD-LTC Application – Appendix D and the Application for Health Coverage & Help Paying Costs. Order online

[PDF] ABD-LTC Application – Appendix D (English)
[PDF] ABD-LTC Application – Appendix D (Spanish)

Applying for the medically needy

Complete Medically Needy Spenddown – Appendix E if you applied for health care coverage for someone who is medically needy, but has income greater than the Medicaid limit and wants to be evaluated for a spenddown based on income, resources, and medical expenses. Spenddown works like an insurance policy deductible. The amount of the “deductible” is called the “spenddown liability.” Once medical bills are equal to or greater than the spenddown liability, the application will be re-evaluated for Medicaid eligibility. Order online

[PDF] Medically Needy Spenddown – Appendix E (English)
[PDF] Medically Needy Spenddown – Appendix E (Spanish)

Applying for persons with special needs

Complete Nursing or Community Based Care – Appendix F if you applied for health care coverage for someone who needs help with everyday things like bathing, dressing, walking or using the bathroom to live safely in the home. Also complete Appendix F if a doctor or nurse has told the person applying that they have a physical disability, chronic (long-term) disease, mental or emotional illness, or addiction disorder. Order online

[PDF] Nursing or Community Based Care – Appendix F (English)
[PDF] Nursing or Community Based Care – Appendix F (Spanish)

To learn more about how to appeal a decision, go to Appeals.

How to send information we ask for

We will send you a letter if we need more information. You can send your information to Virginia Medicaid in one of these ways:

Online: commonhelp.virginia.gov
Email: verify_docs@coverva.org

You can scan and upload, attach electronic copies, or take a photo of your information and attach it to the email. To keep your information secure, this email address only receives information. You will not get a reply.

Mail: Use the address on the letter we send asking for information.
Fax: 1-888-221-9402

For questions, call Cover Virginia at 833-5CALLVA.