Mental health care can be expensive, and therapy costs can quickly add up. Fortunately, if you’re covered by Virginia Medicaid, you may have access to comprehensive mental health and therapy services without the overwhelming financial burden.
Understanding what your plan covers is key to making the most of your benefits. In this article, we’ll break down what mental health services are typically covered, what might not be included, and practical steps to help you use your Virginia Medicaid benefits for mental health care effectively.
Key takeaways
- Virginia Medicaid covers therapy, medications, and community-based mental health services.
- Therapy types include individual, group, family, and trauma-focused care, with options for in-person or online sessions.
- Most behavioral health services no longer require copayments as of July 2022.
- Eligibility depends on factors like income, residency, and specific health needs.
Introduction to Virginia Medicaid
Virginia’s Medicaid program is a joint state and federal initiative designed to provide health coverage to eligible individuals and families across the Commonwealth. This program supports Virginians with diverse needs, including those requiring long-term services, community-based services, and behavioral health care. By offering comprehensive benefits, the program ensures that residents can access necessary health care without facing financial barriers.
Enrollment in Virginia Medicaid is based on factors like income, residency, and specific health conditions. Depending on the individual’s needs, services may be delivered through a fee-for-service model or managed care organizations (MCOs). In either case, beneficiaries are often supported by a care manager who helps coordinate their treatment plans and ensures they receive the services they qualify for, such as therapy, medication management, and crisis intervention.
Who is eligible for Virginia Medicaid?
Eligibility for Virginia Medicaid is based on several factors, including income, residency, and specific health needs. To qualify, applicants must be Virginia residents with income levels that fall within the state’s established thresholds, which vary depending on household size. Virginia Medicaid also considers special circumstances such as age, pregnancy, disability status, and whether an applicant is a parent or caretaker of a minor.
Certain groups receive expanded coverage to address their unique needs. For example, children qualify for comprehensive benefits through the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) program, which ensures access to preventive and developmental care. Pregnant women are eligible for prenatal and postpartum services, while individuals with disabilities may qualify for additional long-term care benefits and specialized health services.
When it comes to mental health care, coverage depends on medical necessity. Virginia Medicaid defines “medically necessary” therapy as treatment that is required to prevent, diagnose, or treat a mental health condition and meets accepted standards of care. A licensed provider typically determines medical necessity through assessments and treatment planning, ensuring that beneficiaries receive services tailored to their needs.
Does Virginia Medicaid cover therapy?
Yes, Virginia Medicaid typically covers therapy, including both in-person and online options, to address a wide range of mental health needs. These services are designed to help individuals manage conditions like substance use disorders, depression, anxiety, stress, relationship challenges, obsessive-compulsive disorder (OCD), and more.
What therapy does Virginia Medicaid cover?
Virginia Medicaid provides coverage for various types of therapy as part of its commitment to quality mental health care. While coverage can vary based on your specific plan, the following types of therapy are typically included:
- Individual therapy
- Group therapy
- Family therapy
- Cognitive behavioral therapy (CBT)
- Dialectical behavior therapy (DBT)
- Trauma-focused therapy
- Substance use counseling and treatment
Depending on your diagnosis, treatment history, and plan details, Virginia Medicaid may also cover other types of therapy, including:
- Psychotherapy for children and adolescents
- Couples therapy (if deemed medically necessary)
- Specialized therapies for PTSD or other trauma-related disorders
Virginia Medicaid also covers mental health services provided by the following types of professionals:
- Licensed therapists and counselors
- Clinical psychologists
- Psychiatrists
- Licensed clinical social workers
Learn more about other types of therapy you might find when seeking mental health care, and be sure to double check your specific Virginia Medicaid health plan, or reach out to Virginia Medicaid directly, to understand what therapy may be covered by your Virginia Medicaid insurance.
Medication coverage with Virginia Medicaid
Virginia Medicaid provides coverage for a wide range of psychiatric medications to support individuals managing mental health conditions. This includes medications commonly prescribed for conditions such as depression, anxiety, bipolar disorder, schizophrenia, and ADHD. Examples of covered medications include antidepressants, antipsychotics, mood stabilizers, and anti-anxiety medications.
For certain high-cost or specialized medications, prior authorization may be required. This means your healthcare provider must submit documentation to Virginia Medicaid explaining the medical necessity of the medication before coverage is approved. While this process can add a step, it ensures that the prescribed treatment aligns with evidence-based guidelines and meets your specific needs.
To confirm whether a specific psychiatric medication is covered under your plan, you can check Virginia Medicaid’s formulary list or consult with your healthcare provider or pharmacy.
What types of therapy does Virginia Medicaid not cover?
Virginia Medicaid covers many types of therapy which may help an individual with their mental health needs. However, there are some types of mental health services which are not covered by Virginia Medicaid. These services include, but may not be limited to:
- Life coaching or personal development counseling
- Career counseling unless directly related to a mental health diagnosis
- Holistic or alternative therapies, such as Reiki, aromatherapy, or acupuncture
- Experimental or non-evidence-based treatments
- Therapy solely for court-mandated purposes (unless deemed medically necessary)
- Residential therapy programs that do not meet Virginia Medicaid’s criteria for medical necessity or therapeutic treatment
Of course, please review your specific plans details, as they vary between plans.
Does Virginia Medicaid cover online therapy?
Yes, Virginia Medicaid covers online therapy, also referred to as telehealth or virtual therapy, in addition to in-person therapy. This includes access to licensed mental health professionals who provide services via secure video or phone platforms. Online therapy offers a convenient and flexible option for individuals who may face barriers to attending in-person sessions, such as transportation issues, physical disabilities, or busy schedules.
However, there are a few important details to keep in mind:
- Provider requirements: The online therapy provider must be licensed in Virginia and enrolled as a Medicaid provider.
- Service types: Not all therapy types may be offered via telehealth, depending on the nature of the treatment and medical necessity. For example, certain group therapies or intensive programs may require in-person attendance.
- Technology needs: You’ll need access to a device with a stable internet connection, as well as a secure platform approved by Virginia Medicaid for telehealth services.
- Prior authorization: In some cases, prior authorization may be required for telehealth therapy services, particularly for specialized treatments.
To confirm your eligibility for online therapy and ensure coverage, review your specific Virginia Medicaid plan or reach out to a Medicaid representative. Your healthcare provider can also help verify coverage and connect you with telehealth resources.
Does Virginia Medicaid cover out-of-network therapy?
Virginia Medicaid may cover therapy with an out-of-network provider in specific instances. If you want to see an out-of-network mental healthcare provider with Virginia Medicaid, it will likely cost much more than seeing an in-network provider. You may have to pay out of pocket, and file for reimbursement with Virginia Medicaid. If you have questions about out-of-network therapy coverage, please refer to your Virginia Medicaid summary of benefits (SOB) as described below, or contact Virginia Medicaid directly.
How Virginia Medicaid covers community-based services
Virginia Medicaid extends its support beyond clinical settings by offering community-based services for eligible residents. These health care services are often provided under waiver programs, which are designed to help individuals receive care in their homes or communities rather than in institutional settings. For example, waivers can cover long-term services like counseling, rehabilitation, or support for individuals with developmental disabilities. They may also cover doctor visits.
Beneficiaries can work with their care manager to determine the most appropriate services for their needs and navigate the enrollment process for specialized programs. Virginia Medicaid ensures access to these services in multiple languages, including English, to support its diverse population. Whether services are provided through a managed care plan or fee-for-service structure, the goal remains the same: to empower residents to maintain their well-being in the community setting of their choice.
How to check if your Virginia Medicaid plan covers therapy
There are three main ways to find out if your Virginia Medicaid plan covers therapy and, if so, what it covers and how much it will cost.
1. Check your Virginia Medicaid “summary of benefits”
On the summary of benefits (SOB), look for a row that references mental health, behavioral health, or substance abuse services, as well as “outpatient services” (because therapy is considered to be outpatient care).
If the “Network Provider” and/or “Out-of-Network Provider” give cost information, such as a copay or coinsurance, then your Virginia Medicaid plan does cover mental health services.
If the “Network Provider” and/or “Out-of-Network Provider” say “not covered”, then your Virginia Medicaid plan does not cover mental health services such as therapy.
To learn more about how summary of benefits are structured, you can refer to this sample SOB from the Centers of Medicare & Medicaid Services website.
2. Contact Virginia Medicaid directly
Contacting Virginia Medicaid directly is the best way to get the exact information you need about what types of mental health care are covered.
To find contact information for Virginia Medicaid, you can:
- Find the phone number to call, located on the back of your insurance ID card
- Use the Virginia Medicaid website to log into your account, and either chat or email a Virginia Medicaid representative directly
3. Use a therapy provider like Grow Therapy
With Grow Therapy, you can search for mental health providers who are in-network with Virginia Medicaid who are licensed in your state and provide both online therapy or in-person therapy. On Grow Therapy, you can browse our growing network of vetted therapists and use filters to search by age, specialty, gender, and more. Simply pick the therapist who meets your unique needs and book your first session.
When booking, you’ll be asked to enter your insurance information to verify eligibility and receive a cost estimate.
How much does Virginia Medicaid therapy cost?
Virginia Medicaid offers comprehensive coverage for therapy services, ensuring that beneficiaries have access to necessary mental health care with minimal out-of-pocket expenses. As of July 1, 2022, most adults enrolled in Virginia Medicaid are no longer required to make copayments for behavioral health services, including therapy sessions.
Prior to this change, copayments for services such as outpatient therapy typically ranged from $1.00 to $3.00 per visit. The elimination of these copayments has reduced financial barriers, making mental health services more accessible to Medicaid members.
It’s important to note that while therapy services are generally covered without copayments, other services under Virginia Medicaid may still have associated costs. For example, copayments for inpatient hospitalization can be $100.00.
For the most accurate and up-to-date information regarding potential costs related to your specific plan and services, it’s advisable to consult your member handbook or contact Virginia Medicaid directly.
Virginia Medicaid therapy copay
When paying for therapy, your copay (or copayment) is an important cost you should know about.
The copay is a fixed amount you have to pay for each therapy session. Copays can vary depending on your plan, as well as the therapist you see, so it’s important to double check your copay under the mental health coverage section on your summary of benefits.
If you have any doubts or questions about if you have to pay a copay, or what your copay is, you should reach out to Virginia Medicaid support directly.
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Does Virginia Medicaid require a referral to see a therapist?
Virginia Medicaid provides access to mental health services, including therapy, without requiring referrals for most plans. Beneficiaries can directly seek care from in-network mental health professionals without prior authorization. However, specific requirements may vary depending on the Managed Care Organization (MCO) administering your plan. For instance, some MCOs may have unique policies regarding referrals and prior authorizations.
To ensure you receive the appropriate care without unnecessary delays, it’s advisable to review your plan’s details or contact your MCO directly. This will help you understand any specific requirements related to accessing therapy services under your Virginia Medicaid coverage.
How to find a therapist covered by Virginia Medicaid
Finding a therapist who accepts Virginia Medicaid insurance is not as difficult as you might think.
1. Virginia Medicaid directory of therapists
Virginia Medicaid offers an online provider directory where you can search for a mental health professional. You can search by provider name, type, language, and location.
Using Virginia Medicaid’s online directory can save you time and effort in finding a mental health provider. Instead of calling multiple providers to see if they accept your insurance, you can quickly and easily find in-network providers in your area with just a few clicks.
2. Contact Virginia Medicaid customer service
To find a mental health professional covered by Virginia Medicaid, you can reach out to their customer service team for guidance. Representatives can help you locate in-network therapists, confirm coverage for specific services, and answer any questions about your mental health benefits.
Here’s how to contact Virginia Medicaid customer service:
- By phone: Call the Virginia Medicaid helpline at 1-800-643-2273. Representatives are available to assist you with finding providers and understanding your coverage.
- Online portal: Log in to your account at Virginia Medicaid’s website to search for providers in your area using their online directory.
- Managed Care Organization (MCO): If your benefits are managed by an MCO, contact their customer service team directly. The MCO’s contact information is typically listed on your Medicaid ID card.
When you contact customer service, have your Medicaid ID number handy and be ready to provide details about the type of mental health care you’re seeking. This will help streamline the process and ensure you receive accurate information.
3. Use Grow Therapy
You can search for an Virginia Medicaid therapist using Grow Therapy. Just select your state, your Virginia Medicaid plan, and any specializations you’re looking for. You’ll then see a list of providers you can choose from, and reach out to schedule a session.
What do terms like deductible, copay, and coinsurance mean?
Navigating the insurance system—especially when you’re in need of mental health support—can be challenging and confusing. For help, please visit our Understanding health insurance article.
Navigating common issues with Virginia Medicaid health coverage
Sometimes, issues can pop up when seeking health care. See why certain challenges may arise, what they mean, and how to address them below.
Denied claims
A denied claim happens when Virginia Medicaid or your Managed Care Organization (MCO) decides a specific service isn’t covered or finds an issue with the way it was billed. This can be frustrating, especially when you believe the service should be included under your plan.
What to try: Start by reviewing your explanation of benefits (EOB) to understand the denial reason. Double-check your plan details to confirm whether the service is covered. If the claim should be covered, contact customer service to clarify any misunderstandings or billing errors. If necessary, file an appeal with Virginia Medicaid or your MCO, including supporting documents like a letter from your provider explaining the medical necessity of the service. Make sure to submit the appeal within the timeframe noted in your denial notice.
Needing pre-authorization
Sometimes, Virginia Medicaid or your MCO requires pre-authorization before covering specific mental health services. This means your provider must request approval before delivering the service.
What to try: Work closely with your provider to ensure they submit all required documentation for the pre-authorization process. Providers are typically familiar with what Virginia Medicaid requires and can help navigate the paperwork. If pre-authorization is denied, ask your provider to clarify or appeal the decision, providing additional information if needed. Staying proactive and following up with your MCO can prevent delays in receiving care.
Other common issues
You may also encounter challenges such as difficulty finding in-network therapists or delayed reimbursements for covered services.
What to try: Use Virginia Medicaid’s online directory or call customer service to locate in-network providers near you. For reimbursement delays, contact your provider’s billing department to ensure claims were submitted correctly and follow up with Medicaid customer service to track the status of your payment. Persistent follow-up and clear communication with your provider and Medicaid can often resolve these issues.
Making the most of your mental health coverage with Virginia Medicaid
Understanding and utilizing your mental health benefits under Virginia Medicaid is key to accessing the care you need. These benefits are designed to provide support for a wide range of mental health conditions, making therapy and other services more affordable and accessible. Taking the time to familiarize yourself with your coverage ensures you can make the most of what’s available.
Policyholders should regularly review their plan details and stay informed about any changes to their coverage. Medicaid policies can evolve, and being aware of updates can help you avoid unexpected barriers to care. If you’re unsure about what’s covered, don’t hesitate to contact customer service or speak with your healthcare provider to clarify your options.
Being proactive about your mental health is one of the best ways to prioritize your well-being. Seek help early, advocate for yourself if challenges arise, and explore preventive care options like wellness programs or stress management techniques. By staying informed and taking charge of your mental health care, you can ensure a comprehensive approach to achieving and maintaining mental wellness.
