The WV Medicaid program provides healthcare to well over 500,000 low-income or disabled people each year. Even though Medicaid is partially federally funded, each state can customize plans according to local needs. This comprehensive guide breaks down the parts of the West Virginia Medicaid program.
Medicaid in West Virginia covers the following services:
Dental coverage for adults only includes emergency services, but kids have coverage for checkups and cleanings, root canals, crowns, sealants, fillings, extractions, dentures, x-rays, orthodontics, and surgical procedures along with related appointments and anesthesia. Vision coverage follows similar regulations. Adults with WV Medicaid have access to limited eye exams and glasses according to medical need. Kids with WV Medicaid have access to regular vision exams and diagnostics, glasses, and contact lenses.
Under the Mental Health Parity and Addiction Equity Act, all Medicaid programs are required to cover mental health and substance abuse disorders in the same capacity as physical ailments. Mental health patients with Medicaid have access to psychiatric hospitals and treatment facilities, psychologists, behavioral health centers, and clinical social workers as well as mental health-related prescription drugs. You may also have access to a Behavioral Health Home (see below).
*If you are in an emergency, please call 911 or the Suicide Prevention Hotline at 1-800-273-8255.
West Virginia Medicaid covers family planning and counseling, pregnancy tests, STI tests, sterilization, and gynecologist services such as pap smears, birth control visits, and lab tests. Maternity care including prenatal, delivery and postpartum care (including newborn doctor services) are all included as well.
Beneficiaries are eligible for both emergency ambulance transportation and non-emergency medical transportation through a company called Logisticare. The non-emergency benefit is available to Medicaid beneficiaries who do not have a reliable means of transportation and need assistance getting to and from various doctors appointments (and in some cases, pharmacies). Your location must be a medically necessary appointment that is covered by Medicaid. To make a Logisticare transportation reservation, call 1-844-549-8353 (TTY 1-866-288-3133). You will need to get approval from your Medicaid plan first to make sure you are covered for this service.
The West Virginia Medicaid program has a comprehensive prescription drug program. The drugs on the preferred drug list will act as your “formulary.” You’ll also find information about prior authorization, meaning that there are certain drugs that you will need to have Medicaid approve before you retrieve your prescription at the Medicaid rate.
Mountain Health Trust and the West Virginia Health Bridge Alternative Benefit Plan are the managed care organizations (MCOs) for the West Virginia Medicaid program. Once accepted into the program, you will receive a packet in the mail which will tell you which MCO program you are in. The main differences between the two programs are a few coverage limits. For example, the Health Bridge program does not include nursing home coverage and has a limit of 24 chiropractic treatments per year. On the other hand, the Health Bridge program allows for 30 physical and occupational therapy visits per year instead of the traditional 20, and 100 home health visits instead of 60. Whichever program you qualify for, you will receive detailed information about your coverage limits in the mail upon your acceptance.
An MCO is a group of doctors and other providers that are responsible for your care. Within your MCO, you’ll need to choose your PCP, or Primary Care Physician. He will be the doctor that you turn to first for all of your and your family’s healthcare needs. Your PCP can refer you to other doctors and specialists. Most people who have West Virginia Medicaid will have to select an MCO, with exceptions for some aged and disabled people, those who have both Medicaid and Medicare, foster children, and those who qualify based on high medical spending. All MCO plans have the same basic coverage, but they do not all include the same doctor network, and some may include extra “bonus” benefits. The four options are called UniCare, The Health Plan, West Virginia Family Health, and Aetna Better Health of WV. Not all plans are available in every county.
In 2010, the Affordable Care Act created the option for Medicaid programs to develop “Health Homes.” These homes provide a coordinated care option for those with chronic conditions. A Health Home is not a residence, but instead a team of healthcare professionals dedicated to your care. They help patients reach stability with their condition(s), help decrease medication reliance and identify substance abuse, and educate patients on their health risks. There are two types of WV Health Homes: Behavioral and Diabetes.
Your Health Home can work with the doctors who treat you now, so taking advantage of the Health Home benefit does not mean that you have to switch doctors! You can also leave the program at any time without risking losing your care providers. To join a WV Health Home, contact the Bureau for Medical Services at 304-558-1700 or KERPO at 304-343-9663. If you already know which Health Home you’d like to use, you can also contact them directly for more information.
The first WV Health Home started in July of 2014 in southern West Virginia. It is a Behavioral Health Home with a focus on bipolar WV Medicaid beneficiaries who have a high risk of developing Hepatitis B or C. There are now Behavioral Health Homes available all across the state of West Virginia.
The Behavioral Health Home provides individualized, well-managed treatment options. West Virginia Behavioral Health Homes coordinate care by referring you to the best community and social support services (both for you and your caregivers), promoting a healthy lifestyle, and providing “transitional” care for when you are transitioning between providers or moving from a facility back to your home. Health Home services come at no cost to eligible Medicaid beneficiaries.
The second type of WV Health Home (started in April 2017) is for members who are at risk of depression and anxiety and are obese, pre-diabetic, or diabetic. Your Health Home team can help you manage your medications, remember your appointments, read and understand your medical test results, help you find transportation to and from medical appointments, and work with or help you find medical specialists in your area.
WV Diabetes Health Homes are available in Boone, Cabell, Fayette, Kanawha, Lincoln, Logan, Mason, McDowell, Mercer, Mingo, Putnam, Raleigh, Wayne, and Wyoming counties.
WVCHIP, or the West Virginia Children’s Health Insurance Program, is a little different from WV Medicaid for adults. Any child whose family’s income is at or below 211% of the Federal Poverty Level may be eligible, regardless of the child’s guardian’s eligibility. WVCHIP includes a bit more coverage than the adult program does, including full dental, doctor services, hospitalization, urgent care, prescription drugs, immunizations, vision, mental health, case management, and more.
Eligibility depends on your household income and the number of people in your household. Even if you do not qualify according to the figures below, you may be eligible if you spend enough money on your healthcare services to find yourself at the numbers below. This is called the “spend down” program and is especially common for people who are aged, blind, and/or disabled.
Women who have breast or cervical cancer, are under the age of 65, and do not have other health insurance may be eligible regardless of income. Additionally, SSI (Social Security Income) beneficiaries will automatically qualify for Medicaid. There is also a Medicaid work incentive for those between the ages of 16 and 65 who are disabled and are working. These people can receive Medicaid even without meeting the income requirements if they pay a $50 enrollment fee and a monthly premium.
Income requirements are as follows:
With the Affordable Care Act in 2010 came a major West Virginia Medicaid expansion that resulted in a 21% decline in the amount of uninsured West Virginians. The expansion allowed people living at up to 138% of the Federal Poverty Level to have access to Medicaid (158% for pregnant women and 300% for kids). This allows people who are employed and earning too much to qualify for Medicaid but still not making enough to cover healthcare to have coverage.
Some beneficiaries will be charged small co-payments for some services*. Pregnant women, kids under 21, and Native Americans are exempt from co-payments. There are no co-payments required for long-term care, hospice, family planning, breast and cervical cancer treatments, or emergency services. Co-payments will never exceed 5% of your household income. They usually range between $0 and $4 for doctor or specialist services and up to $75 for hospital services.
There are out-of-pocket maximums based on your income and the Federal Poverty Level (FPL):
*Co-payments for prescription drugs are the same for everybody and will range from $0 to $3.
You can apply through the healthcare marketplace online or through WV “inroads,” the West Virginia Department of Health and Human Services (DHHS) website for all state benefits. If you prefer, you can also visit your local DHHR office to apply in person or print and complete this form to apply my mail. For help or to apply by phone, call 1-877-7165-1212.
Before you begin your application process, gather relevant documents like your proof of citizenship (birth certificate, citizenship paperwork, etc.), your driver’s license or another form of photo ID, marriage or death certificates, proof of income, and proof of any other health insurance you have.
If you receive Social Security Income, you should have already received a Medicaid card in the mail. If not, visit or call your local DHHR office.
If you are eligible for West Virginia Medicaid and are also over the age of 65, diagnosed with ALS or ESRD, or have been receiving SSDI (Social Security Disability Income) for at least 25 months, you may be “dual eligible.” Dual eligibility means that you can obtain coverage from both Medicaid and West Virginia Medicare. Dual eligible beneficiaries usually qualify for a special enrollment period, which means you can enroll in a dual-eligible special needs plan during any time of year.
Dual eligible special needs plans, or DSNPs, are a form of Medicare Advantage, a type of Medicare plan that provides extra benefits like dental, vision, hearing, and more to those who qualify. Through a West Virginia DSNP plan, you can have all of the major benefits you need at little or no cost. To find out if you qualify and for help selecting a DSNP plan, contact Medicare Plan Finder at 833-438-3676.
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