Jeffrey Wade
West Virginia offers Medicaid insurance to its residents, with eligibility depending on factors such as income level, age, and health status. The program, also known as a managed care plan, helps pay for medical expenses, including doctor visits, prescription drugs, dental, and vision care. West Virginia's Medicaid program also provides additional benefits such as access to a primary care provider, COVID-19 protocols, and Health Homes for those with chronic conditions. Enrollment and eligibility requirements are handled by the West Virginia Department of Health and Human Services (DHHS).
| Characteristics | Values |
|---|---|
| Name of the program | Medicaid |
| State | West Virginia |
| Eligibility | Residents of West Virginia who meet specific eligibility requirements, such as income level |
| Application process | Online through the healthcare marketplace or WV "inroads," in-person at the local DHHR office, by mail, or by phone |
| Required documents | Proof of citizenship, photo ID, proof of income, proof of other health insurance |
| Benefits | Dental, vision, mental health coverage, prescription drugs, early and periodic screening, diagnosis and treatment for members under 21, 24-hour advice from a registered nurse, behavioral health services, emergency care services, etc. |
| Managed care organization | The Health Plan |
| Additional benefits with The Health Plan | Teladoc appointments, access to a nurse, guidance from a health coach |
| Health Homes | Coordinated care option for those with chronic conditions, with two types: Behavioral and Diabetes |
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What You'll Learn
Eligibility requirements
West Virginia Medicaid is available to legally present residents, including the aged, blind, and disabled. There is a five-year waiting period for new immigrants to enroll. The income limits include a built-in 5% income disregard that's used for MAGI-based Medicaid eligibility determinations. Here are the eligibility requirements for West Virginia's Medicaid program:
Infants
Infants aged 0-1 in households with income up to 163% of the federal poverty level (FPL) are eligible for Medicaid.
Children
- Children aged 1-5 in households with income up to 146% of FPL.
- Children aged 6-18 in households with income up to 138% of FPL.
- Children with household income above those levels, up to 300% FPL, are eligible for the Children's Health Insurance Program (CHIP) in West Virginia.
Seniors
West Virginia seniors aged 65 and over who do not meet the financial eligibility requirements can still qualify for long-term care Medicaid through the Medically Needy Pathway. This program allows seniors with high medical expenses to become income-eligible for Medicaid if they "spend down" their income on health insurance premiums, unpaid medical bills, and medical expenses that Medicaid does not cover. The spend-down amount is the difference between one's monthly income and the medically needy income limit (MNIL). In 2025, the MNIL in West Virginia is $200/month for a single applicant and $275/month for a couple. The asset limit for this program is $2,000 for an individual and $3,000 for a couple.
Single Nursing Home Applicants
In 2025, a single Medicaid Nursing Home applicant in West Virginia must meet the following criteria:
- Income under $2,901/month
- Assets under $2,000
- Require a Nursing Home Level of Care
It is important to note that not meeting all of the criteria does not mean one is ineligible or cannot become eligible for West Virginia Medicaid.
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Application process
West Virginia offers Medicaid to its residents, and enrollment depends on meeting specific eligibility requirements. The process of applying for Medicaid in West Virginia involves several steps, which are outlined below:
- Understanding Eligibility: To qualify for Medicaid in West Virginia, you must meet certain eligibility requirements, primarily related to your income level. There is a five-year waiting period for new immigrants before they can enroll in Medicaid.
- Gathering Documentation: When applying for Medicaid, you will need to provide documentation to verify your identity, income, and other relevant factors. This may include pay stubs, tax returns, birth certificates, and Social Security cards.
- Completing the Application: You can apply for Medicaid through the West Virginia Department of Health and Human Resources (DHHR). The application process can often be completed online, by mail, or in person at your local DHHR office. You will need to provide information about your household, income, and current health coverage.
- Waiting for Processing: After submitting your application, it will be processed by the DHHR. The time it takes to process an application may vary, and you may be required to provide additional information during this period.
- Notification of Eligibility: Once your application has been reviewed, you will be notified of your eligibility status. If you are found eligible, you will receive information about your coverage, benefits, and any additional steps to take.
- Selecting a Managed Care Organization (MCO): In West Virginia, you can choose a Managed Care Organization (MCO) that best suits your needs. The MCO will coordinate your healthcare services and provide you with a list of participating providers.
- Choosing a Primary Care Provider (PCP): Each member of your family enrolled in Medicaid will need to select a "primary care provider" (PCP). This is the doctor they will typically see for their health needs. You can choose a PCP through the MCO's website or a similar platform.
- Receiving Member ID Cards: After enrolling in Medicaid and choosing your MCO and PCP, you will receive Member ID cards in the mail. These cards are essential and must be presented each time you visit the doctor or fill a prescription.
- Scheduling the First Appointment: New members of Medicaid are encouraged to schedule their first appointment with their chosen PCP as soon as possible. This appointment is typically for a general health checkup, and you can schedule it by calling the PCP's office phone number listed on your Member ID Card.
- Utilizing Additional Benefits: Depending on your chosen MCO, you may have access to additional benefits, such as online appointments, 24/7 access to nurses, and health coaching services. Familiarize yourself with these benefits and take advantage of them as needed.
It is important to stay updated with any changes or requirements in the Medicaid program, as eligibility reviews are conducted periodically.
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Benefits of Medicaid
Medicaid is a federal and state program that provides health care coverage to people who qualify. Each state runs its own Medicaid program, but the federal government has rules that all states must follow. The federal government also provides at least half of the funding for their Medicaid requirements.
Medicaid is a major source of funding for the US healthcare system, covering 19% of all healthcare spending and 19% of hospital spending. It is the primary payer for long-term care in the United States, covering 61% of total spending.
Medicaid provides health care coverage for people who qualify, based on income and the value of what they own. It is available to the aged, blind, and disabled. For example, in West Virginia, you may qualify for Medicaid if you meet specific eligibility requirements, like falling below a certain income level. If you qualify, you will be able to visit doctors and specialists at little or no cost. You will also receive dental, vision, and mental health coverage. Any prescription drugs that you take will often be less expensive, too.
Medicaid programs may also cover a variety of different Home- and Community-Based Services (HCBS) to help people stay living at home and active in their community. The level of support provided is typically based on the needs of the individual. Examples of the types of home health care and residential senior care services provided as part of HCBS programs include skilled nursing care and occupational, physical, or speech therapy. Other services, such as doing chores around the house and making meals, can be provided by family members, friends, or paid caregivers.
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Health Homes
West Virginia has a Medicaid program, and enrollment for newly eligible residents began on October 1, 2013, with coverage effective from January 1, 2014. The state chose to expand Medicaid over a state-run exchange as it was deemed to provide more value.
Medicaid in West Virginia is also known as a managed care plan. If eligible, you will be able to visit doctors and specialists at little or no cost. You will also receive dental, vision, and mental health coverage. Any prescription drugs you take will often be less expensive, too.
If you select The Health Plan as your Managed Care Organization (MCO), you will also receive extra benefits, including:
- The ability to schedule an online Teladoc appointment, which lets you see a doctor by phone or video.
- Access to a nurse at any time to help you assess your health needs.
- Guidance from a Health Coach who can help you set goals to become healthier.
Each person who is covered by Medicaid will receive their own member ID card. You must bring this with you every time you go to the doctor or fill a prescription. Each member of your family who is enrolled in Medicaid will also need a "primary care provider" (PCP). This is the doctor you will see for most of your health needs. You can choose a PCP for yourself and your family members through the FindaDoc website. All new members should see their PCP as soon as possible for a general health checkup. You can schedule a first appointment by calling the PCP's office phone number, which will be listed on your Member ID Card.
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Spend down program
West Virginia's Medicaid program is administered by the Department of Health and Human Resources (DHHR). Individuals can apply for Medicaid through the DHHR website or by visiting a local DHHR office. An in-person interview is always required when applying for long-term care benefits, but interviews are not required for applicants seeking an MSP.
To qualify for Medicaid in West Virginia, you must meet specific eligibility requirements, such as having an income below a certain level. If you qualify, you can visit doctors and specialists at little to no cost. You will also receive dental, vision, and mental health coverage, and any prescription drugs you need will often be less expensive.
The state of West Virginia has chosen to recover the cost of Medicaid benefits only for enrollees who received nursing home care or HCBS. If West Virginia does pursue estate recovery, it may attempt to recover the cost of all Medicaid benefits for those enrollees (not just LTSS). When an enrollee’s Medicaid coverage was administered by a managed care organization (MCO), the state will attempt to recover what it paid the MCO. This means the estate recovery amount could be more or less than the actual cost of the Medicaid services received. West Virginia will grant an exemption to estate recovery if recovering from an estate would cause undue hardship to an enrollee's heirs.
The state's Medicaid program also includes Medicare Savings Programs and coverage of long-term care services.
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Frequently asked questions
Medicaid is a program that helps pay for medical care.
You may qualify for Medicaid in West Virginia if you meet specific eligibility requirements, such as falling below a certain income level.
You can apply through the healthcare marketplace online or through "inroads", the West Virginia Department of Health and Human Services (DHHS) website for all state benefits. You can also apply in person at your local DHHR office or by mail.
Medicaid benefits in West Virginia include dental, vision, and mental health coverage, as well as prescription drugs. There are no copays for behavioral health and emergency care services.
A Health Home is a team of healthcare professionals dedicated to your care if you have a chronic condition. There are two types of WV Health Homes: Behavioral and Diabetes.
