Medicaid in West Virginia is a vital healthcare assistance program for individuals in need, particularly those who meet certain income and eligibility requirements. This program is jointly funded by the state and federal governments, reflecting a collaborative effort to provide healthcare services to vulnerable populations.

The administration of Medicaid in West Virginia is handled by the Bureau for Medical Services (BMS), which operates under the larger umbrella of the West Virginia Department of Health and Human Resources (DHHR). BMS is responsible for overseeing the smooth operation of the Medicaid program, ensuring that eligible individuals have access to a range of healthcare services.

Medicaid in West Virginia provides a comprehensive range of medical services under different plans, including the Traditional Medicaid Plan, West Virginia Health Bridge, and the Alternative Benefit Plan (ABP), also known as the Expansion Plan. Here is a summary of the covered services and limitations:

Common Services Across All Plans

• Primary and specialty care office visits
• Podiatry and chiropractic services (with a limit of 20 visits per year combined with physical and occupational therapy; additional authorization is required beyond the limit)
• Diagnostic X-ray, outpatient, and inpatient hospital services, including maternity
• Emergency room services and emergency transportation/ambulance
• Hospice, inpatient psychiatric hospital, prescription drugs
• Physical therapy, occupational therapy, speech therapy, cardiac and pulmonary rehabilitation, durable medical equipment, orthotics and prosthetics, laboratory services and testing, diabetes education, family planning services and supplies, nutritional counseling, tobacco cessation, and non-emergency medical transportation (NEMT)
• Early Periodic Screening, Diagnosis, and Treatment

Traditional Medicaid Plan & West Virginia Health Bridge

• Home health (60 visits per year, additional authorization required over the limit)
• Inpatient rehabilitation hospital services

Alternative Benefit Plan (ABP)

• Combined physical and occupational therapy (30 visits per year for habilitative and rehabilitative services)
• Home health (100 visits per year)

Dental Services

• Medicaid members under 21 are eligible for comprehensive dental services
• Adults 21 and older have two levels of dental service: emergent procedures and diagnostic, preventative, and restorative services, with a coverage limit of $1,000 per member per calendar year

Out-of-State Medicaid Coverage

Services are typically required to be from a West Virginia provider, with exceptions for border status providers, emergency treatment out of state, or with prior approval.

Non-Emergency Medical Transportation (NEMT)

Available for Medicaid members who need transportation to keep scheduled medical appointments and treatments, with specific eligibility requirements and procedures.

Eligibility for Medicaid in West Virginia is determined based on various factors, including income and specific personal circumstances. The program is designed to provide health insurance to a range of individuals and groups, including:

1. Supplemental Security Income (SSI) Beneficiaries: These individuals are automatically eligible for Medicaid coverage and do not need to apply separately at the local Department of Health and Human Resources (DHHR) office.
2. Pregnant Women: Their eligibility depends on their Modified Adjusted Gross Income (MAGI) and household size.
3. Children Under Age 19: Eligibility for children is also based on household MAGI.
4. Very Low-Income Families: Their income and household composition determine these families' eligibility.
5. People Who Are Aged, Blind, and/or Disabled: These individuals are considered based on specific criteria for their conditions.
6. Medically Needy Individuals: This category includes those who may not meet the typical financial criteria but require essential medical care.
7. Adults Ages 19 to 64: Eligibility for adults in this age group is based on MAGI and household size.

When determining MAGI, certain types of income are excluded, such as scholarships, child support income, worker's compensation benefits, veterans benefits, and specific American Indian and Alaska Native incomes. Household size for Medicaid purposes is based on federal tax return dependencies, including the applicant, their spouse, dependent children (biological, adopted, or stepchildren), and other dependents.

Check with your county DHHR office to determine if you meet the income guidelines.

Applying for Medicaid in West Virginia involves different procedures depending on whether you receive Supplemental Security Income (SSI) or not:

For SSI Recipients

If you receive SSI, you are automatically eligible for Medicaid. You will receive a medical ID card around the first day of the month when you become eligible for SSI.

For Non-SSI Recipients

If you do not receive SSI, you must apply for Medicaid benefits. There are several ways to do this:

1. Online: Apply through the Health Insurance Marketplace at www.HealthCare.gov.
2. Federal Call Center: Contact the call center at 1-800-318-2596 for assistance.
3. State Website: Apply online at www.wvpath.wv.gov.
4. In-Person or Mail: Submit your application to your local county Department of Health and Human Resources (DHHR) office. These offices are open Monday through Friday from 8:30 a.m. to 5:00 p.m., excluding state holidays. An appointment can be made for convenience. A list of office locations can be found at DHHR Field Offices, or you can call the DHHR Change Center at 1-877-716-1212 for more information.
5. Assistance in Hospitals and Clinics: Many local hospitals and primary care clinics offer staff assistance filling out Medicaid applications.
6. Home Visits for Physically Disabled Individuals: If you cannot visit a local office due to a disability, you can request a staff member to visit your home for the application process. Call your local DHHR office or Client Services at 1-800-642-8589 to arrange a home visit.

In West Virginia, renewing your Medicaid coverage is important to ensure continuous healthcare benefits. Typically, Medicaid needs to be renewed annually, and the renewal process can vary slightly based on individual circumstances.

The West Virginia Department of Health and Human Resources (DHHR) usually sends a renewal notice to Medicaid recipients, informing them it's time to renew their coverage. This notice includes instructions on how to complete the renewal process.

Renewals can often be done online, which is a convenient option for many. The state's WV PATH website (www.wvpath.wv.gov) is the primary online portal for managing and renewing Medicaid benefits.

Alternatively, if you prefer to renew in person or need assistance, you can visit your local DHHR office. It's also possible to continue over the phone by contacting the DHHR.

Respond promptly to the renewal notice and provide any required documentation to avoid a lapse in Medicaid coverage. Additionally, regularly updating your contact information with the DHHR ensures you receive all necessary communications regarding your Medicaid status.