Virginia Medicaid & Waiver Guide

Limitations

Medicaid eligibility does not automatically approve personal care, respite, or a set number of hours. Eden educational resources are not a substitute for official Medicaid, waiver, or health-plan determinations. Rules vary by program, assessment, authorization, and plan. Confirm current details with DMAS, your MCO, and Eden intake.

Important definitions

Short definitions used on this page. Program manuals may phrase lists slightly differently.

• CCC Plus Waiver: Virginia's CCC Plus 1915(c) home- and community-based services waiver. This is a waiver program, not the current name of Virginia's Medicaid managed-care program.
• Cardinal Care: Virginia's Medicaid and FAMIS program brand. All Medicaid managed-care and fee-for-service members are part of Cardinal Care.
• Cardinal Care Managed Care (CCMC): Virginia's current Medicaid managed-care program, effective July 1, 2025. It combined the historic CCC Plus managed-care and Medallion 4.0 programs. Do not confuse CCMC with the CCC Plus Waiver.

Plain-English summary

Cardinal Care versus Cardinal Care Managed Care versus the CCC Plus Waiver, eligibility layers, personal care, respite, consumer-directed services, LRI rules, and official DMAS sources.

Plain-English overview

Virginia Medicaid is branded Cardinal Care. Most members receive services through Cardinal Care Managed Care health plans. Some long-term services require a waiver such as CCC Plus in addition to Medicaid enrollment.

Eligibility layers

Treat each layer separately: Medicaid eligible; waiver eligible if a waiver is required; service eligible; service authorized; authorized hours or units for a date range.

• A Cardinal Care member may still be denied personal care.
• Waiver enrollment does not freeze hours forever — reassessments can change them.
• MCO enrollment is not the same as an LTSS authorization.

Home- and community-based services

Depending on the waiver or state plan and authorization, services may include personal care or personal assistance, companion services, respite, adult day health, and consumer-directed or agency-directed delivery.

Family caregivers / LRIs

Virginia DMAS defines legally responsible individuals as parents or legal guardians of minors, or the participant's spouse. Paid LRI personal care is extraordinary, ADL-focused, and capped. Respite is not available when a paid LRI is providing personal care or assistance.

If you are not in Virginia

Do not copy Virginia LRI, hour, or waiver rules to another state. Confirm with that state's Medicaid program.

Eligibility and applicability

Program rules, assessments, and payer authorization decide what can start. Medicaid enrollment, waiver enrollment, service eligibility, service authorization, and authorized hours are not the same status.

Assessment and documentation

Depending on the program and service, an assessment and supporting documentation may be required. A nurse does not automatically visit first for every request.

Authorization and approval

When authorization is required, the payer or MCO reviews the requested service and hours. Outcomes can include approval, partial approval, a request for more information, or denial. Eden does not approve the benefit.

Hours and limits

Requested, assessed, authorized, scheduled, and EVV-verified hours can all differ. This site does not invent a universal hour number.

How services can interact

Personal care, respite, companion, adult day, and transportation follow separate rules. A plan may authorize one, more than one, or none.

Family caregiver implications

A parent or spouse is not automatically a paid caregiver. Virginia LRI rules apply only in defined relationships and only when the current official policy and authorization allow it.

Agency-directed vs consumer-directed

Agency-directed: a licensed agency is the employer. Consumer-directed: the member or representative is the employer of record, with services-facilitator support where the waiver allows. Eden's typical public role is agency-directed care.

Insurance and MCO implications

Managed-care members usually follow their plan's authorization and appeal process. Fee-for-service members follow DMAS processes. A plan existing on the official roster does not mean Eden is in-network.