Printer Friendly Version Your Guide To Medicaid West Virginia Department of Health and Human Resources

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The information which follows tells you what services are paid for by your Medical Card, what your rights and responsibilities are under the Medicaid Program, and how and where you may receive additional information.

Medical Services
Covered by Medicaid

• Physician's services, wherever provided.
• Hospital inpatient care.
• Outpatient hospital services.
• Emergency room services.
• X-ray and laboratory services prescribed by an authorized practitioner.
• Routine dental care for children and with approval some medically necessary special care such as braces. Adult dental coverage is limited to removal of cysts or tumors, biopsies, treatment of fractures of the jaw bones and some emergency services.
• Prescribed drugs. Most of the drugs that are prescribed by your doctor are covered by the Medicaid Program. Drugs sold over-the-counter must be prescribed by your doctor to be covered. Some drugs have limits and some may require prior approval.

     The Medicaid Pharmacy Program does have a Preferred Drug List (PDL). Your doctor and pharmacist have copies of this list. If the drug that is prescribed for you is not on the list, a prior approval will be required. In most cases, the drug prescribed or a substitute (approved by your doctor) from the list, can be given to you while you are in the pharmacy. If not, a three-day emergency supply of your prescription is always available to you. You should never leave the pharmacy without some of your medicine. As soon as the approval is given, you will be able to get the rest of your prescription.

     You should show your Medicaid card to your pharmacist each time you have a prescription filled. You will be asked to pay a co-pay for each prescription. Children and pregnant women do not have to make this co-payment. It is best to have all of your prescriptions filled at the same pharmacy. By doing this, your pharmacist and doctors can make sure that your prescriptions work together for you.

• Transportation to medical facilities by ambulance or other most appropriate means.
• Artificial limbs, braces, orthopedic shoes, crutches, walkers, wheelchairs and breathing machines, when prescribed by a doctor.
• Eye care services. Comprehensive vision care services are covered for children through age 20. Adult coverage is limited to one pair of eyeglasses following cataract surgery.
• Care in nursing facilities.
• Family planning services.
• Outpatient mental health services.
• Early and Periodic Screening, Diagnosis and Treatment (EPSDT) for children aged 0-20 years, now called Health Check.

This does not include all medical services you can receive through the Medicaid Program. Some types of medical care you may need will require prior approval from the West Virginia Department of Health and Human Resources.

Note: The West Virginia Department of Health and Human Resources does place certain limitations on the extent of services that can be provided and the fees that will be paid.

Persons eligible for the Medicaid Program obtain medical services by presenting their cards to participating physicians, hospitals, pharmacies or other providers of medical services. The medical service provider then bills the West Virginia Department of Health and Human Resources for payment.

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Out-Of-State
Medicaid Coverage

Only the following types of medical services received outside the State of West Virginia are covered under the Medicaid Program:

• Emergency treatment that is received while traveling or visiting out of state,
   or
• Treatment received after prior approval from the West Virginia Department of Health and Human Resources, Bureau for Medical Services for outpatient services, and the West Virginia Medical Institute for inpatient services.

The referring physician must request prior approval.

Out-of-state services are usually not approved if they are available in West Virginia.

All out-of-state providers will have their claims denied for non-emergency medical services unless:

• They have been declared a border provider.

• The services have been prior approved.
 

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Non-Emergency Medical
Transportation Program (NEMT)

The Non-Emergency Medical Transportation Program, or NEMT, consists of cash payments made to Medicaid recipients or vendors on behalf of eligible recipients who need transportation to a medical facility.

Mileage is reimbursed when private automobiles are used. A small meal allowance is available for when overnight lodging is required. Transportation may also be available via common carrier when travel by private automobile is not available.

In order to be eligible for NEMT, a person must be a Medicaid recipient and:

• Have an appointment for any medical treatment that is approved under Medicaid guidelines, and
 
• Receive prior approval from the West Virginia Department of Health and Human Resources before the trip is made.

For more information, contact your local office of the West Virginia Department of Health and Human Resources.

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Managed Care Programs
HMO and PAAS

Managed care is a health system in which a group of health care providers have agreed to coordinate and provide health care. This program is provided to those who are eligible and, in some cases, those who choose to enroll. In most cases, children, pregnant women and families with children are required to enroll in managed care. If you live in a nursing home, long-term care home, children's home, or a treatment facility, you will not be eligible for managed care.

Depending on the county in which you live, you will be asked to choose either a Physician Assured Access System (PAAS) Primary Care Provider (PCP) or an Health Maintenance Organization (HMO). You will receive directions in the mail on how to do this. If you do not understand, please call 1-800-449-8466.

You may change your PCP or HMO by calling 1-800-449-8466. They have lists of HMOs and PCPs who are managed care providers in each county.

The HMOs and the PAAS Program can help you if you have a complaint. You can reach them by calling 1-800-449-8466. You also have a right to a fair hearing as described in the section "Your Rights" of this manual.

The PAAS Program

The Physician Assured Access System (PAAS) is a group of providers who will provide or approve most of your health care needs. You will be asked to choose a Primary Care Provider (PCP).

Before you see a specialist, please contact your PCP. Your PCP must give you a referral. You may make your own appointments. You may make your own appointments for family planning, some vision, hearing and dental services, obstetrical/gynecological and behavioral health services.

Doctors in the PAAS Program have agreed to provide access to 24-hour care. If you have a true emergency, go to the nearest emergency care center. You do not need approval from your PCP for an emergency.

Mountain Health Trust Program - Health Maintenance Organization (HMO)

A Health Maintenance Organization (HMO) is a group of health care professionals - doctors, clinics and hospitals - that will provide most of your health care needs. If you are asked to choose an HMO, you will also be asked to pick a PCP who will handle most of your medical needs.

If you need to see a specialist or you need hospital care, your PCP will set that up for you.

For behavioral health, pharmacy, long-term care, dental, and non-emergency transportation, you will need to show your medical card when getting care. You may ask the local DHHR for help with travel to medical appointments. Always give the provider both your medical card and your HMO card when getting services.

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Notice to all Medicaid Managed
Care Consumers

If you have Medicaid health insurance and you belong to an HMO or PAAS, you have the right to request the following at least once a year by calling 1-800-449-8466:

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How To
Apply For Medicaid

If You Receive Supplemental Security Income (SSI)

If you are receiving a check from Supplemental Security Income Program, you are automatically eligible for Medicaid and should receive a medical card from the West Virginia Department of Health and Human Resources.

If You DO NOT Receive SSI

If you are not receiving an SSI check, you must apply for Medicaid benefits.

Applications are taken weekdays at your local office of the West Virginia Department of Health and Human Resources. For your convenience, you may wish to call for an appointment.

Most local hospitals and primary care clinics have staff available to assist you in making application.

If, because of a physical handicap or disability, you are unable to go to the local office, you may request a staff person to visit your home and take the application. To request a home visit, call your local office of the West Virginia Department of Health and Human Resources or call the Office of Client Services toll free at 1-800-642-8589.

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Determining Eligibility
for Medicaid

Except in the case of pregnant women and children up to age 19 years, eligibility for Medicaid is based on categorical relatedness, income and assets.

Categorical relatedness means that an applicant must be a member of a family with a child who is deprived of support due to the absence, incapacity or unemployment of a parent(s). If the applicant has no children under age 18, the individual must be age 65 or over, blind or disabled.

The second factor considered is an applicant's income and assets. Income is any money a family or individual receives such as wages, pensions, retirement benefits or support payments. Assets include money in the bank, property other than the homestead, and the cash or loan value of certain life insurance.

When applying for Medicaid, you will be asked about your income and assets you own. DHHR staff will inform you of any documentation needed at the time of your application.

The eligibility of pregnant women and children up to age 19 for Medicaid is determined solely on income. There is no asset test. Pregnant women must provide a medical statement confirming pregnancy.

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What is Spenddown?

Individuals and families who are INELIGIBLE for medical assistance (Medicaid) at the time of application because of income higher than the "protected level" may become eligible under the "spenddown" process.

The process of subtracting your medical bills from your family income in order to become eligible for Medicaid is called "spenddown." The month of application, plus five months, equals a period of spenddown consideration. You may use current payments OR the unpaid balance on "old" medical bills in order to meet spenddown and achieve eligibility at the earliest possible time.

However, if you choose to use old bills to meet your spenddown, you may not use them again for the same purpose.

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Your Medical Card

If you qualify for Medicaid, you will receive a medical card. Persons or families already receiving an assistance check from the West Virginia Department of Health and Human Resources or the Supplemental Security Income Program (SSI) will automatically receive a medical card each month on or about the first day of the month.

Your medical card shows that you have Medicaid benefits. For this reason, you should carry it with you at all times, being careful not to lose it or to let anyone else use it.

Your Medicaid card shows a definite period of eligibility for named individuals. You will receive a new medical card each month as long as you are eligible.

If you are a member of an HMO, you will also receive an insurance card from them. You will need to show both cards to the providers when receiving medical care.

Be sure to carry your most recent card and present it to the medical provider each time you need medical care. The provider will usually make a copy of the card. It is against the law to let anyone else use your card.

If you should lose your medical card, notify your local office of the West Virginia Department of Health and Human Resources immediately. Tell them if you are in managed care.

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Other Coverage Cards

If you also have a managed care, insurance or red, white and blue Medicare Card, present these cards when requesting medical services along with your Medicaid card.

Charges for services provided to individuals with HMO, insurance or Medicare coverage must be billed to those payers first. Individuals in PAAS have special rules for providers other than their regular doctor or clinic.

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Other Medical Insurance

Federal regulations mandate that states identify any third party resource available to meet the medical expenses of a recipient. This third party may be an individual, institution, corporation or public or private agency that is liable to pay all or part of the medical costs of the recipient.

Therefore, if you have medical insurance, veterans' coverage, Medicare or any other medical coverage, including court or insurance settlements, they should pay for your care before Medicaid. In order for Medicaid to pay as secondary or teriary, you must follow the plan provisions of your primary insurance, which includes using your plan network of doctors, dentists, facilities, pharmacies and other providers of medical services designated by your plan. You must also follow all pre-certification requirements of your plan. When your insurance is not enough to pay your medical bills, Medicaid may be able to help.

Having other insurance coverage does not affect your eligibility for Medicaid.  If your provider accepts your other insurance and your Medicaid card, you cannot be billed for the primary insurance deductible or co-insurance. The provider will bill Medicaid as your secondary insurance. If you have access to health insurance through your employer, you may be eligible for the HIPP (Health Insurance Premium Payment) Program. This program may pay your insurance premium for you as long as you or a family member are eligible for Medicaid.

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Your Responsibilities

Changes Affecting Eligibility:

As a participant in the Medicaid Program, you have a responsibility to immediately notify the West Virginia Department of Health and Human Resources of any change in circumstances which may affect your eligibility, such as an address change, an increase in income or assets, a change in family members or receipt of insurance, Workers' Compensation, Social Security retroactive settlement or any other type of settlement. Failure to report such changes may constitute fraud. A person is subject to prosecution whenever he/she willfully presents false statements, misrepresentations, impersonations or other fraudulent devices, and/or obtains or attempts to obtain, or aids and abets any person in obtaining medical assistance to which he/she is not entitled.

Keeping Appointments:

You have a responsibility to keep all appointments with doctors, dentists, clinics, laboratories and other providers of medical services. If you are unable to keep your appointment, please notify them immediately.

Do Not Pay for Covered Medical Services:

You should not pay for covered medical services you receive. If you do, there is no way for you to get your money back. The provider of the service must bill the West Virginia Department of Health and Human Resources and payment must be made directly to the provider.

If you sign an agreement with a provider to pay for services that are not covered by Medicaid or seek services not covered by your managed care plan, then you must pay for these services.

You Must Pay for:

You must pay any co-payments that apply to the services you receive.

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Your Rights

Discrimination Prohibited:

Medicaid benefits will be extended in full compliance with the 1964 Civil Rights Act which prohibits discriminatory administration of benefits from federally funded programs because of sex, race, color, religion, national origin, ancestry, age, political affiliation or handicap.

Confidentiality:

Any information obtained from you or concerning you shall be kept confidential. No information regarding applicants or recipients shall be disclosed for any purpose other than those directly concerned with administrative requirements. A copy of the Medicaid Notice of Privacy Practices is at the end of this booklet.

Right To Appeal:

You have the right to appeal if you are not satisfied with the decision regarding your application and/or it is not handled within a reasonable period of time; if you were not allowed to file an application; or if you think you were treated unfairly in any way. Requests for appeals should be directed to your local office of the West Virginia Department of Health and Human Resources.

If you have received notice of a reduction, suspension or termination of a Medicaid covered service, you have a right to appeal that denial or termination through the fair hearing process. The notice that you receive will include an explanation of your appeal rights and a form that you may use to request a fair hearing.

You may represent yourself or use legal counsel, a relative, friend or other spokesperson.

If you appeal prior to the date of termination of a covered service, you may continue the service. However, if the state's action is upheld, the agency may start recovery actions to recoup the cost of the services furnished.

Denial of Payment for Services:

• Your doctor may not have asked for special permission (prior approval) from the Department in order to get certain services paid.
 
• Certain services are not covered by the West Virginia Medicaid Program.
 
• You may have gone beyond the limits of coverage.
 
• You may not have been entitled to a Medicaid card on the date of services.
 
• Your doctor may not have filled out the forms properly, or may not have been a Medicaid provider when the service was rendered.
 
• Your services were not approved by your PAAS provider or should have been billed to your HMO or insurance.



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NOTICE OF PRIVACY PRACTICES

West Virginia Department of Health And Human Resources
Bureau For Medical Services
350 Capitol Street, Room 251
Charleston, West Virginia 25301-3709
(304) 558-1700

Effective date of this notice:  04 / 14 / 2003 

If you have questions about this notice, please contact Client Services at 1-800-642-8589 or the Privacy Officer at the above address or phone. 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.  PLEASE REVIEW IT CAREFULLY

PRIVACY AND YOU 

Your health information is personal and private. The Medicaid Program must keep your heath information private. Your doctors, dentists, clinics, labs, and hospitals send information to us when they ask us to approve and pay for your health care. We must give you this Notice of the law of how we keep your health information private. 

CHANGES TO NOTICE OF PRIVACY PRACTICES 

All Medicaid employees, staff, students, volunteers and other personnel whose work is under direct control of Medicaid must obey the rules in this notice. We have the right to change our privacy practices. If we do make changes, we will send a new Notice right away to all people covered by Medicaid.  We are required to provide this notice of our privacy practices and legal duties regarding health information to anyone who asks for it. 

HOW WE MAY USE AND SHARE YOUR INFORMATION 

The Medicaid program must obey laws on how we use and share your information, such as your name, address, personal facts, the medical care you had and your medical records. Any information shared must be for a reason related to the administration of the Medicaid program. Such reasons include:

• To approve eligibility for medical and dental benefits
• To establish ways to pay for health care
• To approve, provide, and pay for Medicaid health care
• To investigate or prosecute Medicaid cases (like fraud)

Why we may use or share your health information: 

1.  For treatment: Medicaid may need to approve care before you see a doctor, dentist, clinic or other health care provider. We will share information with necessary providers to make sure you get the care you need. For instance, we may use your health records to identify if you need special information about a health problem like diabetes. 

2.  For Payment:  When Medicaid pays your health care bills, we share information with your health care provider and others who bill us for your health care.  We may send some bills to other health plans or groups who pay bills. For instance, if you are taken to an emergency room they may call to see if you are covered.   

3.  For health care operations:  We may use your health records to check the quality of the health care you get. We may also use them in audits, fraud and abuse programs, planning, and managing the Medicaid program. For instance, your prescriptions are reviewed to be sure the medicines can be used together without harm to you. 

4.  For health notices: We may use your health records to provide you with additional information. This may include sending appointment reminders to your address giving you information about treatment options, alternative setting for care, or other health-related related services. 

5. For legal reasons: We may give your information to a court, investigator, or lawyer in cases about Medicaid. This may be about fraud or abuse, to get back money from others that should pay your Medicaid bills, or other issues related to the Medicaid program. If a court orders us to give out your information, we will do so. 

6. To report abuse: We may disclose your health information when the information relates to a victim of abuse, neglect, or domestic violence. We will make this report only in accordance with laws that require or allow such reporting, or with your permission. 

7. Public Health Activities: We will disclose your health information when required to do so for public health purposes.  This includes reporting certain diseases, births, deaths, and reactions to certain medications. It may also include notifying people who have been exposed to a disease.

8. Research: We may disclose your health information in connection with medical research projects. Federal rules govern any disclosure of your health information for research purposes without your permission.

9. For appeals: You or your health care provider may appeal Medicaid decisions made about your health care services. Your health information may be used to decide these appeals.

10. For Eligibility: We may share your information with federal, state, and local agencies when you apply for Medicaid to verify eligibility, and for other purposes related to the administration of the Medicaid program.

11.  For Special Purposes:  We may disclose your information to a member of your family, to your employer for a Workers Compensation claim, for law enforcement or national security purposes, or in case of a disaster. 

WRITTEN PERMISSION 

Medicaid may use or share your information in limited ways. If we want to use your health information in a way not listed above, we must get your permission in writing. If you give permission, you may take it back in writing at any time. 

WHAT ARE MY PRIVACY RIGHTS? 

You have the right to: 

• Ask us to restrict how we use or disclose your health information. The request must be in writing. We may not be able to comply with your request if we have already used your authorization, if the information is needed to pay for your care or if we are required by law to disclose it.
  
• Ask us to communicate with you at a special address or by a special means.
  
• Look at or get a copy of your Medicaid information. A personal representative who has the legal right to act for you may look at and get it for you. We have information about your Medicaid eligibility, your health care bills, and some medical records. To get a copy of your records, ask us to send you a form to fill out.  We may charge a fee to copy and mail the records. We may keep you from seeing parts of your records when allowed by law.
  
• Ask to change information in your records if it is not correct or complete. We may refuse to change the information if Medicaid did not create or keep it, or if it is already correct and complete. You may request a review of the denial or send a letter to disagree with the denial. This letter will be kept with your Medicaid records.
  
• Ask us for a report of information shared about you for reasons other than treatment, payment, or Medicaid operations. You may ask for a list of those with whom we shared your information, when, why, and what information was shared. The list will start on April 14, 2003.
  
• Ask us to send your information somewhere. You will be asked to sign an authorization form to tell us what information to send and where it is to go. The authorization can be used for up to one year, but you may tell us a specific time. You may write to stop the authorization at any time.  
  
• Ask for a paper copy of this Notice of Privacy Practices. You can also find this Notice on our website at: www.wvdhhr.org.

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**** IMPORTANT *****
MEDICAID DOES NOT HAVE FULL COPIES OF YOUR MEDICAL RECORDS. IF YOU WANT TO LOOK AT, GET A COPY OF, OR CHANGE YOUR MEDICAL RECORD, PLEASE CONTACT YOUR DOCTOR, DENTIST, CLINIC, OR HEALTH PLAN. IF YOU ARE IN A MANAGED CARE PLAN, THAT PLAN MAY HAVE INFORMATION ABOUT BILLS PAID FOR YOU AFTER YOU JOINED THE PLAN.  PLEASE CONTACT THE MANAGED CARE PLAN TO LOOK AT OR GET A COPY OF THESE BILLS.

 

How do i ask about my privacy rights? 

If you want to use any of the privacy rights explained in this Notice, please call or write us at: 

Client Services
West Virginia Department Of Health And Human Resources
350 Capitol Street
Charleston, West Virginia 25301-3711
Phone (304) 558-2400 or (800) 642-8589 or Fax (304) 558-4501

How do I complain? 

If you think your privacy rights have been violated and wish to complain, you may contact 

Privacy Officer
Bureau for Medical Services
350 Capitol Street, Room 251
Charleston, West Virginia 25301-3709
Phone (304) 558-1700 or Fax (304) 5584397

 

Privacy Officer
West Virginia Department Of Health And Human Resources
Building 3, Room 546
1900 Kanawha Blvd. East
Charleston, West Virginia 25305
Phone (304) 558-7293 or Fax (304) 558-4141

 

Secretary Of The U. S. Department Of Health And Human Services
Office For Civil Rights
Attention Regional Manager
150 So. Independence Mall West, Suite 372
Philadelphia, PA  19106-3499

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NO RETALIATION 

Medicaid cannot take away your health care benefits or retaliate in any way if you file a complaint or use any of the privacy rights in this Notice.                       

QUESTIONS 

If you have questions about this Notice and want more information, please contact the Privacy Official, WVDHHR-BMS, by phone (304) 558-1700 or by fax at (304) 558-4397..

Copies of this notice are also available at local county offices of the West Virginia Department Of Health And Human Resources. This notice is also available by e-mail.  Contact the Bureau for Medical Services at the above location. This notice is also available on our Web site: www.wvdhhr.org/bms