Medallion 40 explanation photo

Medallion 4.0 Frequently Asked Questions

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The information below is for educational purposes only and should not replace information found on the Medallion 4.0 website or at the Medallion 4.0 telephone hotline, (800) 643-2273.

Q: What is Medallion 4.0?

A: “Medallion” is a group of managed care organizations (MCOs) offered by the Virginia Department of Medical Assistance Services (DMAS) for low-income families. Medallion 4.0, which starts on August 1, 2018, is the newest version of the Medallion program. In Medallion 3.0, families had three insurance plans to choose from. With Medallion 4.0 they will have six.

Q: What is a managed care organization?

A. Managed care is a type of insurance that strives to reduce costs by developing a network of specific doctors, hospitals, labs, pharmacies, etc. who agree to provide all care to its members.

In managed care plans, patient care is coordinated through a Primary Care Physician, or PCP. This doctor, along with other members of the PCP’s medical practice, will provide most of your child’s medical care. If your child needs care that your PCP does not provide, the PCP will refer you to another doctor in the same managed care organization’s network.

When you select one of the Medallion 4.0 managed care organizations, you must use the doctors, hospitals, labs and pharmacies that are part of that organization’s network. There are some exceptions to this rule, but it is important to make sure your child’s doctors participate in your managed care plan.

Q: What Medallion 4.0 plans do CHKD and its doctors participate in?

A: Children’s Hospital of The King’s Daughters, CHKD Medical Group, CHKD General Academic Pediatrics, CHKD Surgical Group and Children’s Specialty Group participate with the following Medallion 4.0 plans:

  • Aetna Better Health of Virginia
  • Anthem HealthKeepers Plus
  • Magellan Complete Care
  • Optima Health Family Care
  • Virginia Premier

Q: You say I can choose a plan, but I just got information in the mail assigning me to a plan.

A: DMAS does assign you to a plan. After you are assigned a plan, you will receive a welcome kit with membership cards and information about your plan, its providers and covered services. You should review this information carefully. If you are concerned that this plan does not fit your needs, you can change your health plan during the first 90 calendar days of your enrollment for any reason. If you were assigned to a new plan effective July 1, 2018, you have until September 28, 2018 to change your plan for any reason.

You may also be able to change to a different plan after the 90-day window has passed, but you must demonstrate a reason why you need to change.

Q: How do I change plans?

A: To change plans, please call the Medallion 4.0 Helpline at 1 (800) 643-2273. Hours are Monday-Friday, 8:30 a.m. to 6 p.m. Or you can request a change online at www.virginiamanagedcare.com.

Q: I was assigned to a new plan and my child’s PCP is not listed in my directory. What can I do?

A: If your child’s current PCP is not in your new plan’s network, you can continue to see your PCP for up to 90 calendar days after the date of your enrollment. During this time a care coordinator with your plan will help you locate a PCP that is in network. You also have the option of changing to another plan during the 90-day window.

Q: Are there other situations when my child can receive care from a provider who is not in my plan’s network?

A: There are certain circumstances where your insurance plan will allow your child to receive care from providers who are not in their network. For instance, care for life-threatening emergencies is always covered. An emergency is a sudden or unexpected illness, severe pain, accident or injury that could cause serious injury or death if not treated immediately. A mental health emergency is when a person thinks about or fears they might hurt themselves or someone else.

In addition, if your child needs care from a medical subspecialist or specialty surgeon, and your plan does not have that type of specialist in network, your plan will authorize care from the out-of-network provider.

With all healthcare and insurance questions, your best course of action is to work closely with your child’s PCP and your insurance company to make sure you understand your child’s medical needs and your healthcare benefits. When you have questions about coverage, call the number on your enrollment card for help.

(757) 668-8931