West Virginia Medicaid Eligibility and Enrollment

As of March 2023, Medicaid in West Virginia provided health care to more than 641,000 people through Medicaid and CHIP programs. The state aims to provide Medicaid to 550,000 residents and has broad eligibility categories to help accomplish this goal. All low-income residents of West Virginia who are struggling to pay for health care may be able to access assistance through West Virginia Medicaid. 

What Is West Virginia Medicaid?

West Virginia Medicaid is an entitlement program that’s financed by the state and federal governments. The program is administered by the Department of Health and Human Resources (DHHR) and provides quality health care for low income residents. West Virginia uses private health insurance companies to provide services for some groups of Medicaid recipients. This is called Mountain Health Trust and is provided by Managed Care Organizations (MCOs). 

What Does West Virginia Medicaid Cover?

West Virginia Medicaid offers a traditional Medicaid plan and the West Virginia Health Bridge Alternative Benefit plan, also known as the expansion plan. Coverage in both is similar; however, service limits may differ. Both plans include a wide range of health services, including home health, primary care office visits, ambulance and durable medical equipment. The expansion plan does not cover certain types of long-term care, including personal care and nursing home care. 

Some beneficiaries may need to pay co-payments for some services. These are based on income level and cannot exceed 5% of a household’s income. Some services, including long-term care and emergency services don’t incur a co-payment, and there are some people including pregnant women and Native American residents who don’t have co-payments. 

Though West Virginia Medicaid generally only covers medical treatments within the state, there are some providers within 30 miles of West Virginia’s borders that are considered in-state providers. Out-of-state treatment may also be paid for if prior approval has been granted by DHHR or in an emergency situation.

Who Is Eligible for Medicaid in West Virginia?

The eligibility criteria for Medicaid in West Virginia vary based on the applicant category a person fits into. In all cases, eligibility is based on financial status, residency and, for some programs, medical status. 

Financial Eligibility

Every resident who receives Supplemental Security Income (SSI) in West Virginia is eligible for Medicaid. People not receiving SSI have to meet certain income and asset limits to be eligible for the program. These limits can differ depending on the benefit a person is applying for but are generally based on the age of the applicant and are expressed as a percentage of the Federal Poverty Level (FPL). 

For pregnant women, children and adults aged 19-64, the household income limits are as follows:

• Children 0-1: 163% FPL
• Children 1-6: 146% FPL
• Children 6-19: 138% FPL
• Pregnant women and newborns: 190% FPL
• Adults 19-64: 138% FPL

Financial eligibility is based on the Modified Adjusted Gross Income (MAGI) and the size of the applicant’s household. The MAGI does not include certain incomes, including child support, veterans benefits and workers compensation. The FPL increases based on the number of people living in a household. West Virginia Medicaid uses federal tax returns to determine the size of a household, which generally includes the applicant, their spouse and any dependents.

Medicaid for long-term care includes those receiving care in a nursing home or intermediate care facility, people on Home and Community Based Care Waivers, and people with a developmental disability who receive care in the home. The income limit for these programs is 300% of the maximum SSI payment for one person, and the asset limit is $2,000 for individuals and $3,000 for married couples. Certain assets, including personal belongings, a vehicle and a home where the applicant or their spouse lives, are not counted when calculating asset value. 

There are some allowances made with these limits. If an applicant has a spouse with a low income still living in the community, they transfer a certain amount for the spouse's living expenses. This is called the Minimum Monthly Maintenance Needs Allowance (MMMNA). In 2020, if the non-applicant spouse earned less than $2,155 per month, they could receive an allowance to bring their income to this amount. 

The other allowance is made for people living in expensive institutions, such as a nursing home. If the institution’s costs are higher than the Medicaid income limit, an applicant with a higher income may qualify. However, individuals must still contribute to the cost of their care. Older adults should also be aware that the cost to care for people aged over 55 may be recovered from their estates after their death. 

Other Criteria

All recipients of Medicaid must be a resident of West Virginia and a U.S. citizen, permanent resident or legal alien. They must also fit one of the specific categories of people eligible for Medicaid in the state. West Virginia’s categories are broad and include:

• SSI recipients
• Pregnant women
• Children under 19
• Very low income families
• People who are aged, blind or disabled
• Adults age 19-64

West Virginia also has a category for people who are “medically needy." This is generally used for waivers or special programs that help specific sections of the population. To be eligible for these programs, applicants must meet the medical requirements, often called functional criteria. Some are very specific, such as women being treated for breast or cervical cancer. People in long-term care programs must meet certain medical requirements, depending on the program. But in broad terms, they must require a nursing home level of care. 

How Do I Enroll in Medicaid in West Virginia?

As people receiving SSI are automatically eligible, they don’t need to apply. A Medicaid card will be sent out to them. 

People not receiving SSI can apply through the Health Insurance Marketplace, either online or by calling 1-800-318-2596. Alternatively, applications can be made directly to the DHHR through the online portal or by phoning 1-877-716-1212.

Residents can apply in person or by mail to their local DHHR office. Paper application forms can be found on the DHHR website. Many hospitals and primary care clinics also have people available to help West Virginia residents apply for Medicaid. People with a disability can also request a visit and can apply without leaving home by contacting their local office or phoning (800) 642-8598.

Contact Information for West Virginia Medicaid

West Virginia Medicaid has a customer service center that can be reached at 1-877-716-1212. Alternatively, email inquiries can be sent through their online contact form.