Department of Medical Assistance Services
GAP Picture

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 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'S NEW?

Cover Virginia System Update

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.


GAP Membership Cards

Effective January 2017, GAP Membership cards will be mailed every other Tuesday by Magellan of Virginia.

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

Medicaid ID Number

Providers and members can use this number to access care until the membership card is received.

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.

Providers may contact Magellan at 1-800-424-4046.

GAP applicants and members may contact Magellan at 1-800-424-GAP9.

Integrated Care Toolkit

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) 424-4536.

Regulations

As of December 6, 2016 The Governors' Access Plan for the Seriously Mentally Ill (GAP) Proposed Regulations have been approved by the Office of the Governor and will be published on the Virginia Regulatory Town Hall beginning December 26, 2016. A public comment period will be open on Virginia Regulatory Town Hall website from December 26, 2016 through February 24, 2017.

Regulations are the official rule that describes how something should be done. In this case that “something” is the GAP. The GAP regulations describe who is eligible, the eligibility determination process, covered and non-covered services, provider requirements, and the enrollee and provider appeals process. The program was implemented through Emergency Regulations in January 2015; prior to the adoption of DMAS original Emergency Regulations this program did not exist.

GAP has two regulation packages: The first, called the Emergency Regulations, is the active/enforceable package. The Emergency Regulations were recently revised to capture the changes from the CY 2016 General Assembly Session. These changes include moving the household income limitation from 60% of Federal Poverty Level to 80% In addition; the Emergency Regulations recognize the Department of Corrections and local and regional Jails as SMI screening entities. (The operational aspects of this are still under development.) The second package is called the Proposed Regulations; these regulations establish the permanent rulemaking steps and will replace the Emergency Regulations once approved.

For more detailed information and to see the both the Emergency and Proposed Regulations you can visit the GAP specific webpage on the Virginia Regulatory Town Hall site.

Income Requirement

As of July 1, 2016 Virginia's GAP demonstration financial eligibility criteria increased from 60% of the Federal Poverty Level (FPL) to 80% FPL. GAP now provides primary care and behavioral health services for Virginians who are uninsured, have serious mental illness, and have incomes at or below 80% of the (FPL).



ARE YOU ELIGIBLE?

To get 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
Resident of VA
Income below 80%* of Federal Poverty Level(FPL)(*80%+5% disregard)
Uninsured
Does not reside in long term care facility, mental health facility or penal institution
Screened and meet GAP Serious Mental Illness (SMI) criteria

See if you could qualify for GAP: GAP Flier - revised 7/1/16

Spanish version: GAP Flier Spanish


WHAT SERVICES DOES GAP COVER?

Behavioral Health
Medical
Care Coordination, crisis line, and Recovery Navigation/warm line services (available through Magellan of VA)Glucometer and diabetic supplies
GAP Case management (available through local Community Services Boards)Lab (outpatient)
Crisis intervention and crisis stabilizationPharmacy
Outpatient behavioral health and substance abuse treatment services (individual, family and group); intensive outpatient substance abuse, and Opioid/methadone treatment servicesPrimary and specialty provider office visits, including evaluation, diagnostic and treatment procedures performed in a physician's office, including therapeutic or diagnostic injections
Psychiatric Services (including Psychiatric evaluation, management, and treatment) Outpatient diagnostic services (limited to MRI and CAT scans, ultrasounds, and electrocardiogram tests including stress tests)
Psychosocial Rehabilitation Services (assessment and treatment) this includes an array of services designed to help an individual to capitalize on personal strengths and independence

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

HOW TO 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 1-800-424-GAP9

NEED ADDITIONAL HELP?

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

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

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

INFORMATION FOR PROVIDERS

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 Fact Sheet ‒ revised 7/1/16

Training: GAP Member Annual Eligibility Renewal

GAP Amendment ‒ Resulting from 2015 General Assembly Budget Action

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