1) State: West Virginia
2) Own or Federal Exchange? Federal Exchange through a plan management partnership model in 2014,
so the federal government will have some of its traditional authority to regulate the private health
insurance markets in West Virginia. However, the partnership arrangement will allow authority and
oversight over the Exchange.
Source: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-State/west-virginia.html
3) Medicaid Expansion? Yes, expanded as of January 1, 2014
Source: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-State/west-virginia.html
4) In all cases – need to designate if rules are associated with Federal or State mandates/coverage
5) What are Medicaid eligibility criteria?

To be eligible for one of the coverages of West Virginia Medicaid or CHIP you 1) must be a West
Virginia resident, 2) in most cases, you must meet financial eligibility requirements (explained in
the chart above), and 3) meet one or more of the categories below:
o a family living with children under the age of 19 years
o
o
o
o
o
o
o

a pregnant woman with or without children
a person who is long-term unemployed
a disabled person
an adult who is working for a qualified employer
a person who is HIV positive
a child under the age of 19 years
an adult caretaker relative living with children under 19 years of age when neither
parent is living in the home
o elderly (65 or older)
o a woman with breast or cervical cancer
o a person in need of long-term care
There are also specific asset rules related to real estate, bank accounts, and securities shown on
the website below.
Source: http://www.medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward2014/Downloads/Medicaid-and-CHIP-Eligibility-Levels-Table.pdf
http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-State/west-virginia.html
http://aspe.hhs.gov/poverty/14poverty.cfm
6) What kind of coverage is available for mental health care?

All approved plans regardless of Federal or State-run Exchanges must cover the same package of
10 benefits, called essential health benefits.
1. Outpatient services, such as doctor visits or tests done outside a hospital. This includes
fertility treatments.
2. Emergency services
3. Hospital stays, including weight loss surgery
4. Pregnancy and baby care
5. Mental health and substance abuse services, including behavioral health treatment
6. Prescription drugs, including generic and certain brand-name drugs
7. Rehab and habilitative services, those that help people recover from an accident or
injury and those that help people with developmental issues.
8. Lab tests
9. Preventive and wellness services, along with those that help people manage chronic
conditions. This includes contraceptives, hormone replacement therapy, and wigs for
people who are balding.
10. Services for children, including dental and eye care (but not eyeglasses)
Source: www.healthcare.gov
7) What kind of coverage is available for substance abuse treatment?

The chart below shows the substance abuse and mental health treatment that West Virginia
Medicaid covers for adults. Most of the services are covered for people under the age of 21, but
are not included here. (Found on the website below)
Source: http://store.samhsa.gov/shin/content/NMH05-0202/NMH05-0202-WV.pdf
8) Does the state allow the court to order treatment and still have it paid by Medicaid?

The court can order treatment and have it paid by Medicaid if the services are covered by
Medicaid (shown in the chart in question 7)
9) What happens to the health care coverage when a participant is sanctioned to jail (not prison)? How
many days can someone be incarcerated before s/he loses their coverage?

Federal health programs will not pay for your care, but jails and prisons are responsible for
providing essential health and mental health services to all inmates. You have a constitutional
right to treatment while in jail or prison and can request it. Medicaid does not pay for any
services while you are in jail or prison. Many states will take your name off their Medicaid list
when you are incarcerated and you will have to re-apply when you are out of jail.

Detainees may apply for Medicaid and CHIP at any point. However, if determined eligible for
Medicaid, eligibility must be suspended while incarcerated, and health care services cannot be
covered by Medicaid until release, except for off-site inpatient medical care lasting 24 hours or
more.

Federal Medicaid law and the regulations promulgated by the Centers for Medicare and
Medicaid Services (CMS) govern when and how individuals both lose access to federal Medicaid
when they are incarcerated and when full coverage can be restored or established for released
inmates. These rules are quite complex and are intertwined with rules of other federal benefit
programs.

Medicaid law requires a discontinuation of federal payment for services (known as federal
financial participation, or FFP) once an individual is in a public institution, including a jail or
prison. However, federal rules on Medicaid eligibility are different from those governing federal
payment for services. While the law prohibits federal payment for services furnished to anyone
incarcerated in jail or prison, it does not require that individuals lose their Medicaid eligibility.

Individuals can retain their status as a Medicaid-eligible person while in jail or prison. States
must use appropriate administrative measures to ensure that no Medicaid claims are filed with
the federal government while the individual is incarcerated, but they can temporarily suspend
an eligible individual from payment status without terminating them totally from the program.
In addition, before terminating someone, states must meet certain federal requirements:
o
States must continue Medicaid to all eligible individuals “until they are found ineligible.”
o
A state cannot terminate an individual from Medicaid until it has conducted a
redetermination of their eligibility, including an ex-parte review.
o
States “have an obligation under federal law to ensure that their computer systems are
not improperly denying enrollment in, or terminating persons from Medicaid.
Source: ACA Jails pdf, http://www.kitsapgov.com/pubdef/Forms/LinkClick.Benefits.pdf,
http://www.bazelon.org/LinkClick.aspx?fileticket=_Ns68MefCJY%3D&tabid=441
10) What happens to an individual’s coverage when they get a new job? (Or lose a job?) Are there any
“grace periods” of coverage?

If a person has insurance through the Marketplace, getting or losing a job will not affect an
individual’s coverage. The person will need to update their information on the Marketplace
when changes occur because subsidies will be adjusted.

If a person has insurance through their job and lose the job, COBRA continuation coverage may
be available. COBRA, which generally applies to employers with 20 or more employees, allows
the individual and his/her family to continue the same group health coverage. An individual’s
cost for coverage may be higher than what the individual was paying before (and is usually
higher than the cost for coverage under special enrollment in a spouse’s plan), but generally the
cost is lower than that for private, individual health insurance coverage. The plan should send a
notice regarding the availability of COBRA coverage. After this notice is provided, the individual
generally has 60 days to elect coverage and it is then available retroactive to the loss of
coverage. COBRA coverage typically lasts 18 months, but may last longer in certain
circumstances.

Once someone is enrolled in Medicaid, they must renew their eligibility at least once a year or
when there is a change in their circumstances, such as an increase or decrease in any public
assistance.
Source: http://www.dol.gov/ebsa/newsroom/fsjobloss.html
11) Are there restrictions related to treatment providers for probationers, substance abuse, or mental
health treatment? Will only certain providers be covered?


Medicaid is the single largest payer for mental health services in the United States. Although
federal law does not contain explicit provisions concerning the exact types of mental health
services that can be provided, all State Medicaid programs provide some mental health services
to enrollees. Treatments providers must meet the conditions shown in question 15 to be able to
practice in West Virginia.
Medicaid reimbursement is available for mental and behavioral health services covered under
various service categories: physician's services, inpatient and outpatient hospital services,
licensed practitioner's services, clinics, rehabilitative services, inpatient psychiatric hospital
services for individuals under age 21, as well as, prescription drugs. Examples of Services in
these categories include: Counseling, therapy, medication management, psychiatrist's services,
licensed clinical social work services, peer supports, and substance abuse treatment.
Source: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Benefits/MentalHealth-Services-.html
12) Is there coverage for residential substance abuse treatment? What are the parameters?

Yes, adult beneficiaries can receive no more than 25 days in a residential substance abuse
treatment facility each year. All residential treatment admissions and lengths of stay must also
be pre-approved by the Medicaid agency. (see question 7)
Source: http://store.samhsa.gov/shin/content/NMH05-0202/NMH05-0202-WV.pdf
13) What is the process and what are the regulations for treatment providers to be able to participate?

West Virginia offers approval for the following services provided by mental health and
substance abuse providers:
o Emergency Services
o Partial Hospitalization/Day Treatment
o Residential Treatment
o Detoxification Services
o Shelter Services

Treatment providers must be properly licensed and meet one of the four conditions below to be
able to practice in West Virginia.

Counselor In Service (CIS):
■ 4 years qualifying experience, including a combination of 1 year experience specific to
chemical dependency; general work experience; and/or accredited degree work
■ 300 hours of supervised practical experience
■ Pass the written ICRC examination
■ Subscribe to WVCBAPP code of ethics

Certified Addictions Counselor (CAC):
■6 years of qualifying experience, including a combination of 3 years of experience specific to
chemical dependency; general work experience and/or accredited degree work
■270 contact hours of education; 70 hours must have chemical or behavioral dependence
specific content and at least 6 of these 70 must be training in ethics specific to addiction
counseling
■ 300 hours of supervised practical experience
■ Pass the ICRC/AODA written exam
■Demonstrate competence in the 12 core functions by obtaining a passing score on the Case
Presentation Method (CPM), the ICRC/AODA oral exam
■ Subscribe to WVCBAPP code of ethics

Certified Prevention Specialist I (CPS I):
■ 4 years volunteer or paid experience
■ 60 credit hours from an accredited college/university
■ 180 documented clock hours of education training
■ Passing score on ICRC written exam
■Competence in the 6 performance domains of Program Coordination, Education and Training,
Community Organization, Public Policy, Professional, and Planning and Evaluation

Certified Prevention Specialist II (CPS II):
■ 6 years of paid experience specific to prevention
■ Bachelor’s degree
■ 270 documented clock hours of education training
■ Passing score on ICRC written exam
■Competence in the 6 performance domains of Program Coordination, Education and Training,
Community Organization, Public Policy, Professional, and Planning and Evaluation
Source: http://www.hhs.gov/partnerships/resources/fbci_counselor_standards.pdf
14) Is dental care covered?


Dental care is an option in the Marketplace, but is not included in the basic plan (except for
children). Up to $3,000 is provided for dental care due to accidental injury NOT related to
chewing/biting
There is very little dental coverage for adults on West Virginia Medicaid. Adult dental coverage
is limited to removal of cysts or tumors, biopsies, treatment of fractures of the jaw bones and
some emergency services
Source: http://www.dhhr.wv.gov/bms/pages/servicescovered.aspx
15) What is the basic primary medical care coverage? Are well-women check-ups included? Is birth
control included?

Yes for both. See question 6.
16) How does family member coverage work?

Go to the healthcare.gov website, choose your state and apply for family coverage. All of the
plans will cover the 10 essential benefits listed above. On the first step, if you and your family is
not eligible for subsides through the healthcare.gov website, it will take you to the West Virginia
Medicaid website to apply for family coverage. Because West Virginia expanded Medicaid, there
will be no people who fall in the coverage gap.
Source: www.healthcare.gov