Department of Medical Assistance Services

FOR INDIVIDUALS AND FAMILIES:

WHAT IS GAP?

On September 8, 2014, Governor McAuliffe announced a significant step toward providing health insurance to uninsured Virginians when he rolled out his plan, A Healthy Virginia. A Healthy Virginia is a ten step plan that expands access to care, improves care for veterans and for individuals with serious mental illnesses (SMI), and enhances value and innovation across our health system.

The first step in the plan was the establishment of the Governor's Access Plan (GAP). The Governor's Access Plan launched in January 2015 to expand healthcare services in Virginia. GAP is a Medicaid plan that provides limited medical and behavioral health care coverage for low income individuals with Serious Mental Illness (SMI). It includes mental health and substance use disorder services, medical doctor visits, medications, access to a 24-hour crisis line, recovery navigation services, and case management.

WHAT IS NEW?

On October 1, 2017 GAP financial eligibility increased to 100%* (includes 5% disregard) of the Federal Poverty Limit.

2017 Income Guidelines*

Effective October 1, 2017

GAP-up to 100% FPL

Household Size Annual Monthly
1 $12,663 $1,056
2 $17,052 $1,422
3 $21,441 $1,778
4 $25,830 $2,153
5 $30,219 $2,519
6 $34,608 $2,885
7 $38,997 $3,250
8 $43,386 $3,617
Each Additional $4,389 $367

Effective October 1, 2017 GAP members also have access to Addiction and Recovery Treatment Services (ARTS) who have a substance use diagnosis. Governor’s Access Plan (GAP) benefit now included expanded community-based addiction and recovery treatment services and coverage of partial hospitalization and residential substance use disorder treatment.

Effective October 1, 2017 GAP members also have access to Mental Health Peer Supports and ARTS Peer Supports which are provided by someone with lived experience with mental health and substance use.

ARE YOU ELIGIBLE?

To be eligible GAP benefits, you must meet ALL of the following:

Eligibility Requirements
Ages 21 through 64
U.S. Citizen or lawfully residing immigrant
Not eligible for any existing entitlement program (Medicaid, TriCare, Medicare)
Resident of VA
Household income below 100%* of Federal Poverty Level(FPL) (*100%+5% disregard)
Uninsured
Does not reside in a nursing home, long term care facility, mental health facility, or correctional facility
Screened and meet GAP Serious Mental Illness (SMI) criteria

HOW DO YOU APPLY?

Applying for GAP Medicaid is a 2 step process. You can start at either step.

1. Completing a GAP eligibility application with Cover Virginia;

● To start the application process contact Cover Virginia #1-855-869-8190


2. Having a GAP SMI Screening done at your local Community Services Board (CSB) or a participating Federally Qualified Health Center (FQHC).

● Find the nearest SMI screening provider by calling Magellan at 1-800-424-GAP9


WHAT SERVICES MAY GAP COVER?

Outpatient Medical Outpatient Behavioral Health Magellan Only Services Substance Abuse Services
Primary & Specialty Care GAP Case Management Care Coordination Screening Brief Intervention and Referral to Treatment
Laboratory Psychiatric Evaluation, Management and Treatment Crisis Line Available 24/7 Intensive Outpatient
Diagnostic Services
  • Physician's Office
  • Outpatient hospital coverage limited to: diagnostic ultrasound, diagnostic radiology (including MRI an CAT) and EKG including stress
Crisis Intervention and Stabilization Recovery Navigation Outpatient therapy (individual, family, group)
Diabetic Supplies Psychological Rehabilitation Opioid Treatment Programs
Outpatient therapy (individual, family, group) Office Based Opioid Treatment
Mental Health Peer Supports Substance Use Peer Supports
Partial Hospitalization
Residential Substance Abuse Services

The GAP Benefit Plan can be found here: GAP Covered Benefits Chart

Magellan Only Services - 1-800-424-GAP9

● Recovery Navigation - Magellan only service provided by people in recovery. It focuses on whole health and what is important to you - mentally, emotionally, physically, and spiritually. A recovery navigator is a person who can talk to you on the telephone. If you live close to them, they can meet with you in person.

● Warm Line - This is an evening and weekend support line operated by people in recovery. You can call if you want someone to listen or need help finding resources to help you with your wellness.

● Care Coordination - Magellan will have a licensed mental health professional available 24 hours, 7 day per week to provide information about covered benefits, how to find a provider, and who to call for medical, pharmacy, and behavioral health needs.

● Magellan 24-hour Crisis Line: 1-800-424-4279

HOW DO YOU REQUEST A GAP MEMBERSHIP CARD?

● Effective January 2017, GAP membership cards will be mailed every other Tuesday by Magellan of Virginia. Providers and members can use the Medicaid ID number to access care until the membership card is received.

● Cover Virginia approval letters to GAP members include the Medicaid ID number (which is highlighted in the sample letter below).

● Providers can also confirm eligibility using the Virginia Medicaid portal. The ARS - Eligibility & Service Limit Inquiry training found under "Provider Resources" on the Medicaid portal can assist providers with information on how to verify coverage.

● If you have questions about your GAP membership card, call 1-800-424-GAP9.

● Sample ID card

Medicaid ID Number

ADDITIONAL RESOURCES

Example of eligible individuals

● Magellan is committed to developing meaningful tools that can help providers offer the best care possible. Magellan created a new section on their website, Behavioral/Medical Care Coordination Toolkit. It is located under the "For Providers" tab and contains several resources to support coordination of care between behavioral and medical providers. Please visit the toolkit frequently, as additional tools and links will be added on an ongoing basis. Magellan also plans to begin adding content to the companion section located under the "For Members" tab entitled "Connecting Your Behavioral/Medical Care Team." This area will soon contain resources to help members self-advocate for a connected care team to support each individual's whole health needs.

In addition, Magellan Healthcare provides Care Coordination services for GAP members. GAP Care Coordination includes identification of the individual's behavioral health, medical and social/community support needs. If you are having difficulty locating/accessing medical or behavioral health services, contact Magellan at (800) 424-GAP9


NEED HELP?

● For comments or questions, please email BridgetheGAP@dmas.virginia.gov

● For questions about eligibility, eligibility renewals, and application process contact Cover Virginia #1-855-869-8190

● For questions about the nearest SMI screening provider, covered services, or accessing providers contact Magellan #1-800-424-GAP9

FOR PROVIDERS:

GAP Demonstration Goals

The three key goals of this Demonstration are to:

● Improve access to health care for a segment of the uninsured population in Virginia who have significant behavioral and medical needs.

● Improve health and behavioral health outcomes of demonstration participants and

● Serve as a bridge to closing the insurance coverage gap for uninsured Virginians.

How to help someone apply

In collaboration with the Virginia Department of Behavioral Health and Development Service (DBHDS) via SAMHSA support (Cooperative Agreements to Benefit Homeless Individuals) Cover Virginia has updated the GAP eligibility portal effective December 21, 2016. Thanks to the support provided by DBHDS and SAMHSA, this system update allows GAP applicants to identify an additional party to receive correspondence from Cover Virginia about their GAP eligibility applications and their re-enrollment requirements. This system update will assist with the completion of applications and re-enrollment as the additional party may be able to better contact the individual and assist with the application or renewal process. The applicant will also receive the same correspondence sent to the additional party. If you have any questions or concerns, please contact Cover Virginia at (855) 869-8190.

List of SMI eligible diagnosis


DOCUMENT / RESOURCES:

● The GAP Formulary is the same formulary used for Medicaid. The formulary can be accessed here: Virginia Preferred Drug List-Fee for Service

● Medical Services ‒ For information on medical services that require authorization under GAP, refer to the DMAS website, Service Authorization section, at the following link: Service Authourization or access KEPRO's web portal at http://dmas.kepro.com

GAP Supplemental Manual

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