Learn About Coverage For Medicaid in West Virginia

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West Virginia Medicaid coverage provides quality medical assistance to qualified patients in the state for free or at a low cost. Each state determines what is covered by Medicaid and what is not. Therefore, covered Medicaid services on West Virginia’s roster may not match up with those on the list in Maryland.

When it comes to what is not covered by Medicaid, beneficiaries are responsible for certain payments. How much is Medicaid when medical services are not covered? Medicaid cost estimates vary depending on the patient, the types of Medicaid insurance involved and the medical services in need.

To learn more about WV Medicaid coverage and costs, review the below sections, which outline:

How Much Does Medicaid Cost in West Virginia?

Some Medicaid services in West Virginia require co-payments from beneficiaries. However, some individuals are entirely exempt from making any co-payments at all. These individuals are Alaskan natives and Native Americans, children below the age of 21, and pregnant women. Note that West Virginia Medicaid coverage for pregnant women is offered up to 60 days after delivery.

Certain Medicaid services do not require co-payments. These include emergency services, family planning, the Breast and Cervical Cancer Treatment Program, Medicaid Waivers, hospice, and long-term care.

West Virginia Medicaid coverage members pay co-payments based on their levels of income. Members whose household income falls below 100 percent of the Federal Poverty Level may not be denied medical services by providers, even if they cannot make co-payments.

How much is Medicaid when a co-payment is involved? The Medicaid cost estimates for the health care-related co-payments cannot total more than 5 percent of a beneficiary’s household income. Members eligible for Medicaid services make the same co-payments regardless of their income. However, out-of-pocket maximums apply.

What Services are Covered by Medicaid in West Virginia?

Medicaid services are available to eligible patients who qualify for medical assistance throughout the state of West Virginia. The expanded Medicaid coverage plan – the Alternative Benefit Plan (ABP) – caters to various medical services and items. However, some Medicaid services have limits attached to them. When this occurs, Managed Care Organizations (MCOs) may offer additional services on a fee-for-service basis.

WV Medicaid coverage includes the following services:

  • Primary care office visits, diagnostic X-rays
  • Hospice and specialty care
  • Emergency room outpatient services, inpatient hospital care, hospital inpatient/maternity and outpatient maternity
  • Psychiatric treatment, rehabilitative psychiatric treatment and inpatient psychiatric hospital visits
  • Cardiac and pulmonary rehabilitation and inpatient rehabilitation hospital services
  • Orthotics and prosthetics and durable medical equipment
  • Family planning services and supplies
  • Podiatry
  • Nutritional counseling
  • Diabetes education

By downloading our in-depth guide, you will learn more about the coverage options for Medicaid.

West Virginia Medicaid coverage may deny payment of prescription drugs or medical bills in some cases. Some of the situations may include: if files have not have been correctly filled out by a doctor, if a patient was not eligible for Medicaid when the service was offered, if a beneficiary was not yet entitled to a Medicaid benefits card on the date the services were offered or if a doctor has not asked for special permission for services that require prior approval.

West Virginia Medicaid services covers Non-Emergency Medical Transport (NEMT) for members that need assistance to keep scheduled medical treatments or appointments. Medicaid coverage only applies to medical services and items supplied by a West Virginia provider.

However, Medicaid coverage in WV has some exceptions to this requirement. Examples include if the treatment was received after prior approval from Medicaid, if the treatment was offered as an emergency while a patient was traveling or visiting out of state, or if the treatment was received from a medical provider practicing within 30 miles of the West Virginia border.

Not all services covered by Medicaid are free and clear of limits. West Virginia Medicaid services provide limited coverage for the following:

  • Physical Therapy (PT) and Occupational Therapy (OT) – The service is restricted to 30 visits per year for Habilitative and Rehabilitative services (combined PT and OT).
  • Chiropractic services – The service is limited to 24 treatments a year. If OT and PT services have not been used in combination with this service, an additional six treatments per year can be authorized.
  • Speech therapy – Only Habilitative and Rehabilitative services are covered.
  • Home health – WV Medicaid only covers 100 visits per year.

West Virginia Medicaid coverage is also available for medically frail members. If an individual is eligible for the adult coverage group and has emotional health conditions, mental or physical conditions that force him or her to reside in a nursing home or limits his or her daily activities, the individual can choose from various Medicaid benefits. Medicaid services provided to applicants that are medically frail require an additional form that allows them to choose the benefit package they want. If no benefit package is chosen, the default offered to adults is assigned.

What Does Medicaid Not Cover in West Virginia?

Although many Medicaid services are covered under the government health care program, there are others considered what is not covered by Medicaid. Generally, Medicaid coverage does not include out-of-state services that are not approved, unless they are not available in West Virginia. At the moment, the only services not covered are:

  • Non-emergency medical transportation.
  • Personal care services.
  • Behavioral health services.

Learn About the Types of Medicaid Insurance in West Virginia

The West Virginia Medicaid Managed Care Program is known as Mountain Health Trust. West Virginia Medicaid coverage is offered by four Managed Care Organizations, or MCOs. When signing up for WV Medicaid, patients will have to choose an MCO. When an MCO is chosen, beneficiaries must then select a primary care provider (PCP), who will handle the majority of medical services needed under WV Medicaid.

West Virginia Medicaid services are provided by: WV Family Health Plan, UniCare, The Health Plan of the Upper Ohio Valley and Better Health (formerly, CoventryCares of WV). If patients should need hospital care or a specialist, the designated PCP will organize this for them.