West Virginia Medicaid covers doctor visits, hospital stays, prescription drugs, pregnancy and children’s care, behavioral health and substance use treatment, dental and vision (with limits for adults), long-term care at home or in a nursing facility, and rides to medical appointments. All of it has to be medically necessary, and some benefits are sharply narrower for adults than for children. Here is what Medicaid covers in West Virginia, where the limits fall, and what you may owe.
Core Medical Care
Every enrolled member has access to the same medical foundation: primary care, specialist visits, immunizations, wellness checkups, urgent and emergency care, hospital inpatient and outpatient services, lab work, and X-rays. Pregnancy-related care, family planning, chiropractic care, physical and occupational therapy, speech and hearing services, and home health are covered as well.1Wellpoint. West Virginia Medicaid Benefits Each managed care plan runs a 24-hour nurse helpline, and disease management programs are available for conditions like asthma and diabetes.
Services only qualify if they are “medically necessary,” meaning they diagnose or treat an illness or injury, improve how a body part functions, maintain functional capacity, or support age-appropriate growth and development.2The Health Plan. Mountain Health Trust Member Handbook SFY26 That standard is what a plan uses when deciding whether to approve a procedure, piece of equipment, or non-preferred medication.
Children Under 21: HealthCheck
Children on Medicaid are covered more broadly than adults. Through HealthCheck, West Virginia’s name for the federal EPSDT benefit, anyone under 21 automatically receives well-child exams, developmental screenings, vision and hearing checks, dental checkups, and immunizations on the schedules set by the American Academy of Pediatrics.3WV DHHR. HealthCheck: What Is It4Disability Rights of West Virginia. Healthcare for Children
The important part for parents: if a HealthCheck screening turns up a problem, Medicaid has to pay for the diagnostic follow-up and the treatment, even when the specific service would not be covered for an adult.5Highmark Health Options. EPSDT Program That rule is what keeps children’s coverage so much wider than adult coverage.
Dental: Full for Kids, Capped for Adults
Children under 21 get the full dental benefit, including exams, cleanings, X-rays, restorative care, orthodontics, oral surgery, and emergency work like jaw fracture treatment and tumor removal.1Wellpoint. West Virginia Medicaid Benefits
Adults 21 and older have diagnostic, preventive, and restorative dental coverage, but it is capped at $2,000 over any rolling two-year period.6Wellpoint Provider News. Benefit Update to Adult Dental Services Cosmetic dental procedures are not covered at all. Anything you spend above the cap is your responsibility, and unused dollars do not roll into the next cycle.7WV Oral Health Coalition. Resources SkyGen USA administers the dental benefit for the managed care plans; to check your remaining balance, call SkyGen at 877-408-0917.
Vision: Full for Kids, Narrow for Adults
Children under 21 are covered for eye exams on the HealthCheck schedule, annual eyeglasses with frames and lenses, repairs, and medically necessary contact lenses for conditions such as keratoconus or severe refractive error.8WV Bureau for Medical Services. Chapter 525: Vision Services
Adults do not get routine eye exams for glasses. A comprehensive eye exam is covered only when it is medically necessary to diagnose or treat an eye condition. Glasses are covered for adults only within 60 days of cataract surgery, and contact lenses only for members with keratoconus or aphakia.8WV Bureau for Medical Services. Chapter 525: Vision Services Sunglasses, anti-reflective lenses, designer frames, spare pairs, and cleaning supplies are not covered for anyone.9Mountain State Spotlight. WV Medicaid Vision and Dental Benefits Shortfalls
Behavioral Health and Substance Use Treatment
Mental health and substance use services are covered across the full range of intensity. On the outpatient side, that includes individual and group counseling, psychiatric evaluations, psychological testing, intensive outpatient programs, and medication management.10Mid-Atlantic Telehealth Resource Center. WV Medicaid Chapter 503: Behavioral Health Rehabilitation Services Inpatient psychiatric care is covered, as is psychiatric residential treatment for members under 21.1Wellpoint. West Virginia Medicaid Benefits
For people with serious and persistent mental illness, Assertive Community Treatment brings a multidisciplinary team into the community rather than requiring the member to come to a clinic.11WV Bureau for Medical Services. Behavioral Health Targeted case management, crisis intervention, day treatment, skills training, and community support services are also covered, and many can be delivered by telehealth.
For substance use disorders, Medicaid pays for medication-assisted treatment with buprenorphine, methadone, and other medications.12National Library of Medicine. MAT Provider Survey in West Virginia
Prescription Drugs
Pharmacy benefits are not run by the managed care plans. The state covers them directly on a fee-for-service basis using a Preferred Drug List approved by the Secretary of the Department of Health and Human Resources.13WV Bureau for Medical Services. Preferred Drug List and Coverage Details
Drugs on the preferred list generally do not need prior authorization. Non-preferred drugs do, and if you need one urgently, a pharmacy can dispense a three-day emergency supply while that authorization is in process. Newly released drugs in reviewed therapeutic classes are treated as non-preferred until the next annual review unless they have FDA priority status. Over-the-counter medications, tobacco cessation products, diabetic supplies, and drugs for end-stage renal disease have their own coverage rules.
Pregnancy and Postpartum Care
Pregnant women with household income up to 190% of the federal poverty level qualify for Medicaid, and those up to 300% can enroll in CHIP.14HealthInsurance.org. West Virginia Medicaid Prenatal visits, labor and delivery, and postpartum care are all covered. State law sets a reimbursement floor of $600 for these services.15West Virginia Legislature. WV Code 9-5-12
Since 2022, postpartum coverage runs for a full 12 months after delivery, up from the old 60-day limit.16Centers for Medicare and Medicaid Services. HHS Approves 12-Month Extension of Postpartum Medicaid and CHIP Coverage Once a pregnant member is enrolled, she keeps coverage through that 12-month window even if household income later changes.15West Virginia Legislature. WV Code 9-5-12
Family Planning
Family planning services carry no copay and are available to women, men, and adolescents of reproductive age. Covered contraception includes birth control pills, IUDs (ParaGard and Mirena), the Nexplanon implant, Depo-Provera injections, the NuvaRing, the Xulane patch, condoms, foam, diaphragms, vaginal contraceptive film, and Plan B. Tubal ligation and vasectomy are also covered.17WV DHHR. Family Planning Program Services The visit itself can include pregnancy testing, STD screening and treatment, pap tests, pelvic exams, clinical breast and testicular exams, and preconception counseling.18WV DHHR. Family Planning Program Eligibility
Medical Equipment, Prosthetics, and Orthotics
Durable medical equipment such as hospital beds, wheelchairs, CPAP devices, patient lifts, insulin pumps, and pneumatic compression devices is covered. Items are typically rented month to month for up to 13 months, after which ownership transfers to the member.19CMS. WV State Plan Amendment 22-0004 You will need a face-to-face encounter documented within the previous six months, a written order from your prescriber, and a Certificate of Medical Necessity from the equipment vendor.20Acentra Health. DME Services
Prosthetic limbs, artificial internal organ replacements, and orthotic braces are covered when medically necessary, and payment includes the design, fitting, and training. Repairs are allowed when the device is out of warranty, and replacement is covered for a change in your condition, accidental damage, or wear beyond a reasonable useful lifetime of at least three years. Convenience upgrades, over-the-counter orthotics, and experimental devices are not covered.21Wellpoint. Prosthetics and Orthotic Devices Reimbursement Policy
Hospice
Hospice coverage is available for members whose life expectancy is six months or less. The benefit includes nursing care, physician services, medical social services, counseling (including dietary counseling), medications for symptom control, durable medical equipment, short-term inpatient care for respite or pain management, home health and homemaker services, and rehabilitation therapies for symptom control.22WV DHHR. WV Medicaid Chapter 509: Hospice Policy Children under 21 can receive hospice at the same time as curative treatment. Electing hospice means waiving standard Medicaid coverage for services related to the terminal illness unless they go through the hospice program.
Long-Term Care at Home: Waiver Programs
West Virginia runs four home and community-based waivers for people who would otherwise need institutional care. Each targets a different population and has its own menu of services.23Medicaid.gov. West Virginia Waiver Descriptions
- The Aged and Disabled Waiver covers adults 65 and older, and adults 18 to 64 with physical disabilities, who meet a nursing facility level of care. Services include personal attendant care, adult medical day care, skilled nursing, case management, home and vehicle modifications, personal emergency response systems, and non-medical transportation.
- The Intellectual/Developmental Disabilities Waiver covers children and adults age 3 and older with intellectual or developmental disabilities. Services include day habilitation, in-home support, respite, supported employment, skilled nursing, occupational and physical therapy, speech therapy, behavioral support, crisis intervention, and environmental adaptations.
- The Traumatic Brain Injury Waiver covers people age 3 and older with brain injuries, including personal attendant services, case management, community transition services, and home and vehicle modifications.
- The Children with Serious Emotional Disorder Waiver covers ages 3 through 21 and includes in-home family support, respite, wraparound facilitation, family therapy, peer parent support, job development, and specialized therapy.
Waivers require both medical and financial eligibility. The state also runs a Personal Care Services Program for members who need help with activities of daily living and a Take Me Home program that helps nursing facility residents move back into the community.24WV Bureau for Medical Services. Home and Community-Based Services Waivers
Nursing Home Care
Medicaid is the primary payer for nursing home care in West Virginia and covers stays in nursing facilities and intermediate care facilities for people with intellectual disabilities when both medical and financial criteria are met.25WV Bureau for Family Assistance. Medicaid and Medicaid Long Term Care
A single applicant generally cannot have more than $2,000 in countable assets, and monthly income cannot exceed the cost of the nursing home by more than $200. Residents keep $50 a month as a personal needs allowance.26Legal Aid of West Virginia. Paying for Nursing Home Care: Medicaid The home (under specific conditions), one car, household furnishings, clothing, burial plots, and pre-paid funeral contracts are exempt from the asset count.
When one spouse enters a nursing home and the other stays at home, spousal impoverishment rules let the community spouse keep at least half of the couple’s combined countable assets, up to a Community Spouse Resource Allowance of $162,660 in 2026.27MedicaidPlanningAssistance.org. Medicaid Eligibility in West Virginia A 60-month look-back applies to asset transfers; gifts or transfers for less than fair value during that window trigger a penalty period of disqualification proportional to what was given away.28WV DHHR. Medicaid Income Maintenance Manual Chapter 17 If a resident is temporarily hospitalized, Medicaid pays bed-hold fees for up to 12 days per calendar year for medical reasons and up to 6 days for non-medical reasons.
Transportation
Non-emergency medical transportation to and from covered appointments is a Medicaid benefit, managed statewide by the broker Modivcare. You can book a ride at 844-549-8353 (Monday through Friday, 7 a.m. to 6 p.m.) or through the Modivcare online portal or mobile app. Routine trips need at least five business days’ notice; urgent requests and hospital discharges are handled around the clock.29WV Bureau for Medical Services. Non-Emergency Medical Transportation: Information for Members If you live near a bus line you can ask for transit passes, and if a friend or family member drives you, you may qualify for mileage reimbursement.30Aetna Better Health of WV. Modivcare NEMT Flyer
Emergency ambulance transport is covered, including air ambulance when ground transport would endanger your health. Air ambulance payment is limited to transport to the nearest appropriate acute care hospital; if air transport is used when ground would have been adequate, payment drops to the ground rate.31Highmark Health Options. Air Ambulance Policy
What You Pay: Copays
Many members owe no copays at all. There are no copays for children 20 and younger, pregnant members through 60 days postpartum, American Indians and Alaska Natives, hospice patients, nursing home residents, or anyone who has hit their household’s quarterly copay cap. Family planning, emergency services, and behavioral health services are also copay-free regardless of income.1Wellpoint. West Virginia Medicaid Benefits
For everyone else, copays rise with household income relative to the federal poverty level. An office visit is $0 at or below 50% FPL, $2 between 50% and 100%, and $4 above 100%. Inpatient hospital stays are $0, $35, or $75 across those same tiers. Non-emergency use of the emergency room costs a flat $8 at any income level.
Total copays per household are capped each quarter, from $8 for households with quarterly income up to $1,966 to $143 for households at $3,933 or more. Once you hit the cap, you pay no further copays for the rest of the quarter.
What’s Not Covered or Is Limited
Beyond the adult dental cap and the narrow adult vision rules already covered, several other limits apply:
- Cosmetic dental work is excluded, and procedures like nose or jaw reconstruction need prior authorization to confirm they are medically necessary rather than cosmetic.
- Adult chiropractic care is limited to 24 treatments per year; more require prior authorization.
- If a member revokes hospice three times, they lose future hospice eligibility.
- Under the Medicaid expansion Alternative Benefit Plan, personal care services and long-term institutional care are not covered, though they remain available under the traditional state plan for eligible populations.32Medicaid.gov. WV Alternative Benefit Plan SPA 21-0008
How the Coverage Reaches You: Managed Care Plans
Most members get their benefits through one of four managed care organizations: Aetna Better Health of West Virginia, The Health Plan, Highmark Health Options, and Wellpoint (formerly UniCare).33WV DHHR. Managed Care Organizations After Medicaid approves your application, you pick a plan through Mountain Health Trust. If you don’t pick, you’ll be assigned one, and you can switch at any time by using the Mountain Health Trust website, calling 1-800-449-8466, or returning a mail-in form.34Aetna Better Health of WV. Choose a Plan
All four plans cover the same core medical benefits. They differ on value-added extras, which can include gift card incentives for wellness visits and vaccinations, free cell phones with data, gym memberships, weight management programs, GED support, maternal health kits, gas cards, and youth camp scholarships.35Mountain Health Trust. MHT and CHIP Comparison Chart A separate program, Mountain Health Promise, is administered by Aetna and serves children and youth in foster, kinship, and adoptive care.
A few important benefits sit outside the managed care plans and are paid directly by the state on a fee-for-service basis: nursing home care, pharmacy, organ transplants, and non-emergency transportation.2The Health Plan. Mountain Health Trust Member Handbook SFY26 If you have a question about those services, your managed care plan will usually point you to the right place rather than handling it directly.