Medicaid Costs and Coverage in West Virginia

How much does Medicaid cost in West Virginia and is a common question that beneficiaries ask after their application for Medicaid has been approved. Knowing how much is Medicaid is dependent on several factors, such as personal eligibility and services needed. In West Virginia, services that the program covers range from emergency care to vision and hearing screenings to family planning, with a wide variety of services in between. However, some services covered by Medicaid require prior approval, and it is important for the beneficiary to know which services this includes. While Medicaid coverage in West Virginia includes many services, Medicaid beneficiaries might have to pay a portion of the cost, which may include copayments. A copayment is a small amount of the overall total bill that a beneficiary will be responsible for paying when he or she obtains certain health care services. Copayments will vary depending on the beneficiary, and some members may be exempt from copayments altogether.

How much does Medicaid cost in West Virginia?

In West Virginia, how much does Medicaid cost will vary base on the types of Medicaid insurance and from beneficiary to beneficiary. Medicaid insurance is a joint program between both the state and the federal government. According to federal Medicaid coverage guidelines, states can impose copayments, deductibles, co-insurance and other charges on most Medicaid-covered services, and the numbers that the state can charge will vary with income. Medicaid cost estimates also state that all of the out-of-pocket charges are based on the state’s payment for that service. Pharmacy copayment under coverage of Medicaid is the same for all medical members regardless of their income, but out-of-pocket maximums do apply.

According to West Virginia Medicaid cost estimates, beneficiaries will have a maximum out-of-pocket (OOP) payment for each quarter for every calendar year, which is the most that a beneficiary will ever be required to pay in any given quarter, regardless of the number of health care services that they receive. Typically, out-of-pocket Medicaid costs in WV apply to all Medicaid beneficiaries except those specifically exempted by law, and most beneficiaries are limited to nominal amounts. Exempted groups for West Virginia Medicaid coverage include children, terminally ill beneficiaries and those beneficiaries residing in an institution. Since coverage of Medicaid generally covers low-income and very sick beneficiaries, Medicaid services cannot be withheld for failure to pay. However, beneficiaries may be held accountable for unpaid copayments, so it is important to know share-cost information about Medicaid covered services.

What Medicaid services in West Virginia require copayments?

Copayments for West Virginia Medicaid coverage are based on a beneficiary’s income, and copayments may not exceed five percent of the household income. Medicaid cost estimates in WV state that providers are not allowed to deny services to a beneficiary whose household income is less than 100 percent of the Federal Poverty Level (FPL) due to his or her inability to make payment of a copayment.

In West Virginia, some beneficiaries who have Medicaid coverage will be expected to pay for copayments for specific services. Beneficiaries who are exempt from Medicaid copayments include the following:

  • Pregnant women, including pregnancy-related services for up to 60 days post-partum
  • Children younger than 21 years of age
  • Native Americans and Alaska natives
  • Long-term care
  • Hospice

Medicaid coverage states that services can also be exempt from copayments. After completing the Medicaid application process in West Virginia, applicants will learn about their eligibility for these Medicaid cost waivers for services that fall under breast and cervical cancer treatments, family planning and emergency services.

What services are covered by Medicaid in West Virginia?

West Virginia Medicaid coverage of services include a wide range of health care treatments and supplies. Generally, services covered by Medicaid include those that are medically necessary to treat or prevent illness. These services include but are not limited to, primary care office visits, specialty care, podiatry, chiropractic, diagnostic X-ray, inpatient and outpatient hospital services. Additional services include an emergency room, nursing home services, emergency transportation and ambulance, inpatient and outpatient maternity care. Coverage of Medicaid in West Virginia also includes outpatient psychiatric treatment, rehabilitation psychiatric treatment, inpatient psychiatric treatment and prescription drugs.

Under Medicaid coverage in West Virginia, there are a few services that have service limits. Beneficiaries will need to know which services are covered by Medicaid for a limited amount, as they will be financially responsible for uncovered costs. While Physical Therapy (PT) and Occupational Therapy (OT) are covered under WV Medicaid, there is a limit of 20 visits per year for combined PT and OT. Additional authorization is needed if a beneficiary goes over the limit. Medicaid costs in WV state that there is a limit to 60 visits per year for home health services and additional authorization is also needed if a beneficiary goes over the limit. For some health care services, these limits are set by the beneficiary’s Medicaid eligibility in West Virginia.

Also included in the full coverage of Medicaid in WV is speech therapy, pulmonary rehabilitation, cardiac rehabilitation, orthotics and prosthetics, durable medical equipment, inpatient rehabilitation hospital services, laboratory services and testing and diabetes education. In West Virginia, Medicaid coverage also includes long-term care such as nursing home care, intermediate care facilities for beneficiaries with intellectual disabilities, aged and disabled waiver services, intellectual and developmental disabilities waiver services and traumatic brain injury waiver services. Additionally, early periodic screening, diagnosis and treatment, family planning services and supplies, nutritional counseling, tobacco cessation and personal care services are also included.

When it comes to transportation, Medicaid coverage costs for West Virginia state that Non-Emergency Medical Transportation (NEMT) is available to those Medicaid beneficiaries who need assistance to keep a scheduled Medicaid treatment or appointment. For a beneficiary to be eligible for NEMT, he or she must have Medicaid coverage in WV and an appointment for a medical treatment that has been approved under Medicaid guidelines. Download our comprehensive Medicaid guide for more details about services covered by the program, including details about which services are mandatory.

What does Medicaid not cover in West Virginia?

While there are many services covered by Medicaid in West Virginia, there are also some that are not covered. A Medicaid beneficiary may receive Medicaid coverage from an out-of-state provider, except for specific circumstances. Many medical providers who practice within 30 miles of the West Virginia border are granted “border status.” In turn, these medical providers are considered in-state providers and they do not have to obtain previous approval for services except in those situations where it is required of in-state providers. Under Medicaid coverage in WV, this includes the emergency treatment that is received for a beneficiary while traveling or visiting out of state or treatment that is received after previous approval from the Medicaid program. Medicaid coverage for out-of-state services is usually not approved for beneficiaries if they are available in the state. Learn more about the government health insurance program by downloading our detailed national Medicaid guide here.