West Virginia

In West Virginia:
  • As of July 1, 2011, there were 326,749 beneficiaries enrolled in the state’s Medicaid program, 166,555 of whom were enrolled in one of three commercial managed care organizations through Medicaid’s Mountain Health Trust managed care program.
  • Physical and oral health services are provided through the Medicaid MCOs; beneficiaries who do not voluntarily enroll in an MCO receive these services through fee-for-service Medicaid. Behavioral health services are reimbursed on a fee-for-service basis.
  • A Children with Disabilities Community Services Program, supported through a home and community-based services waiver, provides supports to severely disabled children in the community.
As of 2013, 220,597 individuals were eligible for West Virginia’s Early Periodic Screening, Diagnostic and Treatment Benefit (EPSDT), known in the state as HealthCheck. According to 416 data from 2013, the state achieved an EPSDT screening ratio of 100% and a participant ratio of 54%. 102,216 children received dental services of any kind, with 90,102 receiving preventive dental services.
Last updated September 2014
Medical Necessity

Medicaid provider manuals in the state define medical necessity as:


“Services or supplies that are proper and needed to diagnose or treat a medical condition.”

Initiatives to Improve Access
Primary care providers participating in a Medicaid managed care organization’s provider network must provide 24-hour, seven-days-per-week access.
West Virginia’s Medicaid agency encourages providers to deliver services using telehealth to improve access for beneficiaries. Providers with the appropriate infrastructure can receive reimbursement for services delivered via telehealth and must use a service code modifier when billing.
Reporting & Data Collection
Medicaid managed care organizations in West Virginia are required to report to the state quarterly on:
  • EPSDT screening and referral rates,
  • Well-child visit rates
  • Dental visits, and
  • Immunization rates.
Behavioral Health
West Virginia’s Medicaid program requires that a developmental screening be administered with a standardized screening tool at the 9-month, 18-month, and 30-month well-child visits.
The HealthCheck Provider Manual instructs providers to conduct autism surveillance at all well-child visits. Primary care providers are also expected to use a standardized autism-specific screening tool to conduct screens at the 18-month and 24-month well-child visits.
Support to Providers and Families
Support to Families
West Virginia hosts a HealthCheck website with information for parents on covered services and preventive health resources. The website has a tool that allows parents to enter their child’s birth date to find out what the family can expect at the child’s next well-child visit.
Support to Providers
The HealthCheck website also contains resources for providers, including a series of History and Preventive Health Screening Forms for each well-child visit on the periodicity schedule. Information updates notify providers of policy changes affecting HealthCheck.  A Developmental Tool Kit and an Oral Health Tool Kit offer provider education to help providers satisfy the American Academy of Pediatrics’ Bright Futures guidelines.
A detailed HealthCheck Provider Manual offers information on the EPSDT benefit and components of a well-child visit.
Care Coordination
West Virginia Medicaid employs six HealthCheck Outreach Workers who try to assist a medical home model of care delivery, connecting children with primary care providers who coordinate the child’s care.
Managed care organizations have a number of responsibilities to coordinate care for Medicaid beneficiaries, including:
  • Formally designating an individual or entity responsible for coordinating a beneficiary’s care,
  • Developing systems to assure referrals and case management,
  • Coordinating physical services with behavioral health services received through fee-for-service providers,
  • Coordinating with school-related health services,
  • Coordinating with delivery of community and social services, and
  • Working with local health departments to avoid duplication of services.
West Virginia is partnering with Oregon and Alaska on a CHIPRA demonstration grant to support a Tri State Children’s Health Improvement Consortium. The state is working with ten pediatric practices to support care coordination and transformation of those practices into patient-centered medical homes.
Oral Health
Children’s oral health services are provided through Medicaid managed care organizations (MCOs). Each MCO must have a Dental Director and each is required to educate its provider network about the state’s Infant and Child Oral Health Fluoride Varnish Program for Primary Care Practitioners program, which reimburses Medicaid primary care providers for applying fluoride varnish to young children. The MCOs are also responsible for ensuring continuity of dental and orthodontic care for Medicaid beneficiaries.


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