The national Medical Plans guide covers plan types, cost sharing and the ACA. This guide covers Virginia's rules for health coverage: dependent and newborn mandates, rating limits, HMOs, health services plans, short-term plans and FAMIS. Individual policy provisions and group continuation are in the Virginia Individual A&H Provisions and Group Health guides.

Dependents and newborns

• Dependents to age 26: coverage must be available until age 26. It can't depend on financial dependency, residency, marriage, student status, employment or other coverage (38.2-3439).
• Newborns are covered from the moment of birth, including congenital defects (38.2-3411).
  • Coverage includes medically necessary dental, oral surgery and orthodontic care for cleft lip or palate and ectodermal dysplasia.
  • The policy may require notice and premium within 31 days of birth.
• Adopted children are covered from placement (38.2-3411.2).
  • A child placed within 31 days of birth is treated as a newborn from placement.
  • An adopted child can't be restricted because of a preexisting condition.
• Handicapped dependents: proof of incapacity is due within 31 days of the limiting age. After two years, proof can be required no more than once a year (38.2-3409).
• Medical child support orders: the child must be enrolled without regard to enrollment-season limits, even if living elsewhere (38.2-3407.2).

ACA-related state rules

• No lifetime or annual dollar limits on essential health benefits (38.2-3440).
• Individual and small group rating may vary only by individual or family coverage, rating area and age, at no more than 3 to 1 for adults (38.2-3447).
• Genetic information can't be used to deny, limit or price coverage (38.2-508.4).

HMOs and health services plans

HMOs

• An HMO provides or arranges health care plans (38.2-4300).
• Basic services include emergency care in and out of the area, hospital and physician care, mental health and substance use benefits, and preventive services.
• Copayments may be dollar amounts or coinsurance, but not on required preventive services (14VAC5-211-90).
• After the out-of-pocket maximum is met, the HMO must stop charging cost sharing. It notifies the enrollee within 30 days after processing enough claims, and refunds any overcharge.
• Enrollees choose a primary care professional and may switch, subject to availability (14VAC5-211-140).

Health services plans

• A nonstock corporation licensed under Chapter 42. Covered people are called subscribers (38.2-4201).
• It can't refuse to pay for covered services just because a listed practitioner provided them. Examples are chiropractors, optometrists, psychologists and podiatrists (38.2-4221).

Short-term and excepted coverage (14VAC5-141)

• Short-term limited-duration coverage lasts 3 months or less. With renewals, it can't exceed 6 months in 12 months.
  • Ads must say it's not minimum essential coverage.
  • Preexisting exclusions are limited to 3 months in 12.
• A minimum-essential-coverage policy can't be replaced with short-term or excepted-benefit coverage unless the insured asks in writing.

FAMIS

FAMIS is Virginia's children's health program. It covers uninsured children under 19 in families at or below 200% of the federal poverty level who don't qualify for Medicaid. There's no cost sharing for well-child and preventive care (32.1-351).

Common exam traps

• Dependents to 26, regardless of student or marital status.
• Newborns are covered from birth. Notice and premium may be required within 31 days. Cleft lip and palate care is included.
• Adult age rating: 3 to 1 at most.
• Short-term plans: 3 months, and 6 months total in 12.