Virginia's Health Insurance Exchange and Medicaid Expansion: What Producers Must Know

Virginia made two foundational changes to its health coverage landscape in the past decade: Medicaid expansion in January 2019 and the launch of its own state-based insurance marketplace in fall 2023. Together, these changes significantly expanded coverage access for low- and middle-income Virginians and created a more complex coverage navigation environment for producers. Understanding how the Virginia Insurance Marketplace works, what Medicaid expansion covers, how the two interact, and what the current federal policy landscape means for Virginia clients is essential for any Life and Health producer serving Virginia's individual and small-group markets.

Virginia's Insurance Marketplace: From Federal to State-Based

Virginia's insurance marketplace went through three distinct phases:

2014–2022: Virginia operated through the federal exchange at HealthCare.gov as a federally facilitated marketplace (FFM). Virginia consumers enrolled through the federal site.

2022–2023 transition: Virginia began the process of transitioning to a state-based exchange platform.

Fall 2023 onward: Virginia launched its own state-based exchange, branded as Virginia's Insurance Marketplace (marketplace.virginia.gov). For all plans with effective dates of January 1, 2024 or later, enrollment goes through the state platform. The Virginia Health Benefit Exchange (VHBE) administers the state marketplace.

Why this matters for producers: Producers working with Virginia clients on marketplace coverage need to use the Virginia state platform, not HealthCare.gov, for plan selection and enrollment. Certified application counselors, navigators, and licensed producers who assist clients with marketplace enrollment must be familiar with the state platform's interface, plan availability, and subsidy calculation tools.

What the Virginia Marketplace Offers

For Plan Year 2026, Virginia's marketplace offers plans from 8 insurers (down from 10 in 2025). Plans are available in four metal tiers (Bronze, Silver, Gold, Platinum) plus catastrophic plans for eligible consumers under age 30 or with hardship exemptions.

Open enrollment: November 1 through January 30 for Virginia's marketplace in 2025/2026, with coverage starting February 1 for applications submitted January 1–30. If coverage effective January 1 is needed, enrollment by December 31 is required.

Premium tax credits (subsidies): Federal premium tax credits reduce monthly premiums for eligible enrollees whose income falls between 100% and 400% of the Federal Poverty Level (FPL). The enhanced subsidies enacted under the American Rescue Plan and extended through the Inflation Reduction Act had expired as of December 31, 2025 — as of mid-2026, approximately 335,000 Virginians who had relied on enhanced subsidies face significantly higher premiums. The federal legislative status of extended subsidies was unresolved as of early 2026.

Virginia reinsurance program: Virginia's reinsurance program, which took effect in 2023, helps reduce premiums for consumers who do not receive subsidies (those above 400% FPL) by absorbing a portion of high-cost claims. This program has helped moderate rate increases for higher-income enrollees.

Medicaid Expansion: Virginia's Cardinal Care Program

Virginia expanded Medicaid under the ACA effective January 1, 2019, making adults aged 19–64 with incomes up to 138% of the Federal Poverty Level (FPL) eligible for Medicaid coverage.

Current enrollment: As of early 2025, approximately 595,000 Virginians were enrolled under the Medicaid expansion guidelines, out of more than 1.7 million total Medicaid enrollees statewide.

Cardinal Care branding: Virginia unified its Medicaid program under the Cardinal Care brand in October 2023 when the state merged its two legacy managed care programs (Medallion 4.0 and CCC Plus) into a single Cardinal Care Managed Care (CCMC) program. All Medicaid and FAMIS members are now Cardinal Care members.

Current MCOs (as of July 2025): Aetna, Anthem HealthKeepers Plus, Humana Healthy Horizons (replaced Molina effective July 1, 2025), Optima/Sentara, and UnitedHealthcare.

FAMIS (Family Access to Medical Insurance Security): Virginia's CHIP program, covering uninsured children in families with incomes up to 205% FPL depending on age and program.

How the Marketplace and Medicaid Interact

The income-based coverage ladder in Virginia:

Producers who assist clients with coverage navigation must understand where Medicaid eligibility ends and marketplace eligibility begins — this line determines whether a client applies at DMAS (Medicaid) or through the marketplace platform.

Federal Policy Risk: OBBBA and Medicaid Cuts

The federal One Big Beautiful Bill Act (OBBBA) signed in 2025 includes significant reductions in federal Medicaid funding and new work requirements for expansion enrollees. Virginia hospitals and advocates have projected that Virginia could lose $3.3 billion in federal Medicaid funding, with approximately 365,000 eligible Virginians potentially being disenrolled from Cardinal Care. As of mid-2026, the implementation timeline for these changes was still developing — producers should stay current on Virginia's DMAS website for the latest enrollment and eligibility guidance.

Frequently Asked Questions

What is the role of a certified insurance producer in the Virginia Marketplace?

Licensed Virginia insurance producers can assist clients in enrolling in marketplace coverage, but must be certified by the Virginia Health Benefit Exchange (VHBE) as a certified broker to do so through the state platform. Certification requirements include completing VHBE's broker training, registering through the marketplace platform, and complying with the exchange's standards of conduct. Certified brokers can receive compensation for marketplace plan enrollments through the standard commission structure established by VHBE. Producers who enroll clients in marketplace plans without VHBE broker certification are not complying with exchange requirements. Contact VHBE at marketplace.virginia.gov for current broker certification requirements.

How does Virginia's Medicaid expansion interact with the marketplace for someone whose income fluctuates?

Income fluctuations during the year can shift a Virginia consumer between Medicaid and marketplace eligibility. If a client's annual income is projected to be at or below 138% FPL, they should apply for Cardinal Care through their local Department of Social Services (DSS) or through the Virginia Medicaid online portal. If income rises above 138% FPL, they may become eligible for marketplace coverage with premium tax credits. Virginia's easy enrollment program (implemented in 2021) allows consumers to check both Medicaid and marketplace eligibility as part of the state tax filing process. Producers who serve lower-income clients should be familiar with the handoff between the two systems and help clients avoid coverage gaps when income changes.

What should producers know about the impact of expiring federal subsidies on Virginia marketplace clients?

The enhanced premium tax credits enacted under the American Rescue Plan (ARP) and extended through the Inflation Reduction Act expired on December 31, 2025. This affected approximately 335,000 Virginians with incomes above 400% FPL who had relied on those enhanced credits to keep premiums affordable. A consumer who paid $150–$200 per month under the enhanced credits may face premiums of $900 or more for the same coverage level in 2026 without the enhancement. As of early 2026, Congress had not yet extended the subsidies. Producers with marketplace clients in this income range should have frank conversations about whether marketplace coverage remains financially viable, what plan design changes (higher deductibles, narrower networks) might reduce premiums, and whether any employer coverage options are available.

Does Virginia have an individual mandate requiring health coverage?

Virginia does not have its own state-level individual mandate. The federal individual mandate penalty was reduced to $0 by federal legislation effective 2019, effectively eliminating enforcement. Unlike some states (California, Massachusetts, New Jersey, Rhode Island, and the District of Columbia, which have maintained or enacted state mandates), Virginia has not enacted a state penalty for going without health insurance. Producers should not advise Virginia clients that they face a tax penalty for going uninsured at the state level — this is incorrect. The absence of a mandate makes the voluntary value proposition for health insurance (protection from catastrophic costs) the primary enrollment driver, rather than penalty avoidance.

What is FAMIS, and who does it cover in Virginia?

FAMIS (Family Access to Medical Insurance Security) is Virginia's CHIP (Children's Health Insurance Program), which provides comprehensive health coverage for uninsured children in families whose income is too high for Medicaid but who cannot afford private insurance. FAMIS Plus covers children at higher income thresholds than regular Medicaid (up to 205% FPL depending on age and program). FAMIS MOMS covers uninsured pregnant women up to 205% FPL. Applications are submitted through the same process as Medicaid — at the local DSS or online through commonhelp.virginia.gov. For producers who work with families navigating coverage, understanding FAMIS is important because it is the coverage option for children in families above Medicaid's adult expansion threshold.

Virginia's health coverage landscape — the state-based marketplace, Medicaid expansion under Cardinal Care, and the ongoing federal policy uncertainty — creates a dynamic advisory environment for Life and Health producers. Producers who stay current on platform changes, eligibility rules, and federal funding developments provide client value that generic policy placement cannot.

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