Eecve March 1, 2020
Your Guide to
Medicaid
2020
A program administered by the West Virginia Department of
Health and Human Resources, Bureau for Medical Services
2 Eecve March 1, 2020
Introducon
Authorized under Title XIX of the Social Security Act, Medicaid is an entlement
program nanced by state and federal governments and administered by the state.
The Bureau for Medical Services (BMS) is the single state agency responsible for
administering the West Virginia Medicaid Program. BMS is administered by the West
Virginia Department of Health and Human Resources (DHHR).
This booklet provides you with a brief overview of the West Virginia Medicaid Program
and the services available to you. The informaon in this book should not be
considered Medicaid policy. It is intended as a resource to answer some of the
quesons you may have. If you have quesons that are not answered in this book,
please call the phone numbers provided.
Mission Statement
The Bureau for Medical Services is commied to administering the Medicaid Program,
while maintaining accountability for the use of resources, in a way that assures access
to appropriate, medically necessary, and quality health care services for all members;
provide these services in a user friendly manner to providers and members alike; and
focus on the future by providing prevenve care programs.
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Table of Contents
Page
Who is Eligible for Medicaid ................................................................................ 4
Medically Needy and Other Special Eligibility Groups .......................................... 5
Applying For Medicaid ......................................................................................... 5
Required Informaon and Documentaon ........................................................... 6
Your Medical ID Card ............................................................................................ 6
Other Medical Insurance ...................................................................................... 7
Medically Frail ..................................................................................................... 7
Medical Services Covered by Medicaid ................................................................ 8
Out-of-State Medicaid Coverage ........................................................................ 10
Denial of Payment for Services .......................................................................... 10
Non-Emergency Medical Transportaon ............................................................ 10
Co-Payments ...................................................................................................... 11
Member Liability…………………………….………………………………………………………………..12
Your Medicaid Rights and Responsibilies ......................................................... 13
Noce of Privacy Pracces ................................................................................. 15
Mountain Health Trust-Managed Care ............................................................... 18
Medicaid Managed Care Consumer Rights ......................................................... 19
Important Telephone Numbers .......................................................................... 19
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Who is Eligible for Medicaid
Medicaid provides health insurance to:
• Supplemental Security Income (SSI)
beneciaries;
• Pregnant women;
• Children under age 19;
• Very low income families;
• People who are aged, blind, and/or disabled;
• Individuals determined “medically needy”
(some examples of those who may be medically
needy are described on the next page); and
• Adults ages 19 to 64.
Medicaid eligibility is determined based on income
and other factors, depending on your eligibility
category. Eligibility is determined by West Virginia
Department of Health and Human Resources
(DHHR) workers in county oces.
SSI Income beneciaries are automacally eligible
for Medicaid coverage and do not have to apply for
benets at the local DHHR oce.
For pregnant women, children, and adults ages 19
to 64, eligibility is dependent on their Modied
Adjusted Gross Income (MAGI) and household size.
Income not counted when determining MAGI
includes:
• Scholarships, grants and awards for educaonal
purposes;
• Child support income;
• Worker’s compensaon benets;
• Veterans benets; and
• Certain American Indian and Alaska Nave
income.
Household size is based on who is claimed as a
dependent on your federal tax return. This may
include:
• You;
• Your spouse;
• Your dependent children (biological, adopted,
or stepchildren); and
• Other relaves and even non-relaves who
qualify as dependents.
The chart below provides general guidance for 2020
on whether you and/or your family may qualify for
Medicaid based on MAGI. Check with your county
DHHR oce to determine if you meet the income
guidelines.
Family
Size
Children
Ages 0 to 1
Children
Ages 1 to 6
Children
Ages 6 to 19
Adults
Ages 19 to 65
Pregnant
Women and
their Newborns
Yearly Income up
to 163% FPL
Yearly Income up
to 146% FPL
Yearly Income up
to 138% FPL
Yearly Income
up to 138% FPL
Yearly Income
up to 190% FPL
1 $20,799 $18,630 $17,609 $17,609
N/A - family
includes unborn
baby(ies)
2 $28,102 $25,171 $23,792 $23,792 $32,756
3 $35,404 $31,712 $29,974 $29,974 $41,268
4 $43,706 $38,252 $36,156 $36,156 $49,780
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Women diagnosed with breast or cervical cancer
by a Centers for Disease Control and Prevenon
(CDC) program under the age of 65 and do not have
other health insurance may qualify for Medicaid
coverage when certain other non-nancial
requirements are met.
Some Medicare recipients may be eligible to
receive assistance from Medicaid in paying the
Medicare Part A and/or B premium and/or
Medicare co-payments and deducbles.
Medicaid Coverage for Long-Term Care
Medicaid long-term care includes:
• Nursing home care;
• Intermediate care facilies for individuals with
intellectual disabilies;
• Aged and Disabled Waiver services;
• Intellectual/Developmental Disabilies Waiver
services; and
• Traumac Brain Injury Waiver services.
Medicaid Work Incenve (M-WIN) is for individuals
between ages 16 and 65 who have a disability and
are working. Individuals must meet nancial and
asset levels. In addion, the individual must pay a
$50 enrollment fee and a monthly premium based
on income.
In order to qualify for any of these services, a
person must meet nancial and asset limits as well
as certain medical criteria.
Some individuals and families who are ineligible for
Medicaid at the me of applicaon, because of
income higher than the maximum allowed level,
may become eligible under “spenddown.” The local
DHHR worker will explain this process if it is
applicable to the individual.
Medically Needy and Other Special Eligibility Groups
Applying for Medicaid
If you receive Supplemental Security Income (SSI),
you are automacally eligible for Medicaid and will
receive a medical ID card on or about the rst day
of the month you become eligible for SSI.
If you do not receive SSI, you must apply for
Medicaid benets:
• Online at the Health Insurance Marketplace at
www.HealthCare.gov;
• Contact the Federal Call Center at 1-800-318-
2596;
• Online at www.wvpath.org; or
• In person or via mail to your county DHHR
oce, which is open Monday through Friday
from 8:30 a.m. to 5:00 p.m., except on state
holidays. For your convenience, you may call for
an appointment. A list of oces can be found at
www.dhhr.wv.gov/bcf/; or call the DHHR
Change Center at 1-877-716-1212.
Many local hospitals and primary care clinics have
sta available to assist you in lling out an
applicaon.
If, because of a physical disability, you are unable to
go to the local oce, you may request a sta
person to visit your home and take the applicaon.
To request a home visit, call your local DHHR oce
or Client Services toll free at 1-800-642-8589.
Once you have applied for Medicaid, you will
receive nocaon informing you if you are eligible
or if the local DHHR oce needs more informaon
from you.
6 Eecve March 1, 2020
When applying for Medicaid, you must aest to
being a West Virginia resident and a United States
cizen or a legal alien. Non-U.S. cizens will be
asked for an immigraon document and ID number.
Examples of an immigraon document include:
• Permanent Resident Card, “Green Card” (I-551);
• Reentry Permit (I-327);
• Refugee Travel Document (I-571);
• Employment Authorizaon Card (I-766);
• Machine Readable Immigrant Visa (with
temporary I-551 language);
• Arrival/Departure Record (I-94/I-94A);
• Arrival/Departure Record in Foreign Passport
(I-94);
• Foreign Passport;
• Cercate of Eligibility for Nonimmigrant
Student Status (I-20);
• Cercate of Eligibility for Exchange Visitor
Status (DS2019);
• Cercaon from U.S. Department of Health
and Human Services (HHS) Oce of Refugee
Reselement (ORR); and
• Alien Number (also called alien registraon
number or USCIS number) or 1-94 Number.
If you need assistance establishing your immigraon
status, contact your county DHHR oce. All
applicants must be given a reasonable opportunity
to provide documents to establish U.S. cizenship or
immigraon status, unless we can verify this
informaon electronically.
All applicants will need to provide the following
informaon:
• Social Security Numbers (or document numbers
for any legal immigrants who need insurance);
• Employer and income informaon for everyone
in your family (for example, from paystubs, W-2
forms or wage and tax statements);
• The number of people you will claim as a
dependent on your tax return, or if you will be
claimed as a dependent by someone else on
their tax return;
• Policy numbers for any current health
insurance; and
• Informaon about any job-related health
insurance available to your family.
The informaon you provide will be used to
determine if you qualify for Medicaid and the
coverage type. DHHR will also check your answers
using informaon already in its databases and
databases from the Internal Revenue Service (IRS),
Social Security, the Department of Homeland
Security, and/or a consumer reporng agency. If the
informaon does not match, you may be asked to
provide proof that your answers are correct.
All informaon provided to DHHR will be kept
condenal and secure, as required by law.
Required Informaon and Documentaon
If you qualify for Medicaid, your medical ID card will
be included with your approval noce. If you lose or
misplace the card, you can get a replacement card
by:
• Logging in to your WVPATH account at
www.wvpath.org and reprinng the approval
noce.
• Calling the DHHR Customer Service Center at
1-877-716-1212; or
• Calling your case worker at the local DHHR oce;
• Prinng a Leer of Creditable Coverage.
The Leer of Creditable Coverage is valid only for
the day on which it is printed. To print the leer, go
to www.wvmmis.com and click on Member at the
top of the page. Enter your name (or the name of
the person whose card is needed that day), date of
birth, and the last four digits of the Social Security
Number.
It is important to keep your appointments with the
local DHHR oce so your Medicaid eligibility will
connue uninterrupted.
If you are a member of Mountain Health Trust, the
WV Medicaid managed care program, you will also
Your Medical ID Card
7 Eecve March 1, 2020
You may have other health insurance and still be
eligible for Medicaid. Your private insurance
(employer, Medicare, etc.) will be the primary payer
and will pay your health care provider first.
Medicaid will be your secondary insurance and will
pay what your private insurance does not pay (up to
the limit of what Medicaid pays). You cannot be
billed for deductibles or co-payments if your
provider accepts your other insurance and your
Medicaid card.
If you receive money from an insurance company or
as a result of a lawsuit for medical care, you must
use it to pay the provider. If Medicaid has already
paid for your care, a refund must be made to
Medicaid.
If you have access to health insurance through your
employer, you may be eligible for the Health
Insurance Premium Payment (HIPP) Program. This
program may pay your insurance premium for you
as long as you or a family member is eligible for
Medicaid.
Other Medical Insurance
receive an insurance card from them.
When you visit a medical provider, you need to
present your medical ID card along with any other
private or public medical insurance cards you have,
such as your Medicaid managed care card; your
red, white, and blue Medicare card; or your private
insurance card.
Be sure to carry your most recent medical ID card
with you at all mes and present it to the medical
provider each me you need medical care.
If you lose your managed care card, please contact
your Managed Care Organizaon (MCO).
Remember: It is against the law to let anyone else
use your card.
Example of a Medical ID Card
If an individual in your household qualies for the
adult expansion coverage group and has a physical,
mental or an emoonal health condion that limits
daily acvies or forces the individual to reside in a
nursing facility, the aected individual has a choice
of benet packages. You may choose between the
alternave benet package provided to adults
enrolled in Medicaid and the tradional Medicaid
plan that includes expanded services.
If you meet the denion of medically frail at
anyme, you may report this to your county DHHR
oce or to 1-877-716-1212.
Medically Frail
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Medical Services Covered by Medicaid
Benet Provided
Tradional Medicaid Plan
West Virginia Health Bridge
Alternave Benet Plan (ABP)
(Expansion Plan)
Covered Service Limits Covered Service Limits
Primary Care Oce Visits X X
Specialty Care X X
Podiatry X X
Chiropracc X X
Limit of 24 treatments per
year. An addional 6
treatments per year can
be authorized if OT and PT
services have not been
ulized in combinaon
with this service.
Diagnosc X-Ray X X
Outpaent Hospital Services X X
Hospice X X
Nursing Home X Not Covered.
Emergency Room
Outpaent Hospital Services
X X
Emergency Transportaon/
Ambulance
X X
Inpaent Hospital Care X X
Hospital Inpaent/
Maternity
X X
Outpaent/Maternity X X
Outpaent Psychiatric
Treatment
X X
Rehabilitave Psychiatric
Treatment
X X
Inpaent Psychiatric
Hospital
X X
Prescripon Drugs X X
9 Eecve March 1, 2020
Benet Provided
Tradional Medicaid Plan
West Virginia Health Bridge
Alternave Benet Plan (ABP)
(Expansion Plan)
Covered Service Limits Covered Service Limits
Physical Therapy X
20 visits per year
(combined PT and OT,
addional authorizaon
required over limit).
X
30 visits per year for
Habilitave and
Rehabilitave services
(combined PT and OT).
Occupaonal Therapy X
20 visits per year
(combined PT and OT,
addional authorizaon
required over limit).
X
30 visits per year for
Habilitave and
Rehabilitave services
(combined PT and OT).
Speech Therapy X X
Habilitave and
Rehabilitave services.
Cardiac Rehabilitaon X X
Pulmonary Rehabilitaon X X
Durable Medical Equipment X X
Orthocs and Prosthecs X X
Home Health X
60 visits per year
(addional authorizaon
required over limit).
X 100 visits per year.
Inpaent Rehabilitaon
Hospital Services
X X
Laboratory Services and
Tesng
X X
Diabetes Educaon X X
Early Periodic Screening,
Diagnosis and Treatment
X X
Family Planning Services
and Supplies
X X
Nutrional Counseling X X
Tobacco Cessaon X X
Non-Emergency Medical
Transport (NEMT)
X X
Personal Care Services X Not covered.
10 Eecve March 1, 2020
Out-of-State Medicaid Coverage
You must receive your Medicaid services from a
West Virginia provider except in the following
circumstances:
• Some medical providers praccing within 30
miles of the West Virginia border have been
granted “border status”. These medical
providers are considered in-state providers and
do not have to obtain prior approval for
services except in those instances where it is
required of in-state providers;
• Emergency treatment that is received while
traveling or visiting out of state; or
• Treatment received after prior approval from
Medicaid.
Out-of-state services are usually not approved if
they are available in West Virginia.
Denial of Payment for Services
There are certain reasons why Medicaid may deny
payment of your medical bills or prescription drugs:
• Your doctor may not have asked for special
permission (prior approval) for 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; or
• Your doctor may not have filled out the forms
properly or may not have been a Medicaid
provider when the service was rendered.
Non-Emergency
Medical Transportation
Non-Emergency Medical Transportaon (NEMT) is
available to Medicaid members who need
assistance in order to keep scheduled medical
appointments and treatments.
In order to be eligible for NEMT, a person must be a
Medicaid member and have an appointment for
medical treatment that is approved under Medicaid
guidelines.
Eecve September 1, 2018, for more informaon,
to request gas mileage reimbursement, or schedule
a trip, please call the Medicaid NEMT broker at 1-
844-549-8353, Monday-Friday from 7 a.m. to 6 p.m.
at least ve business days before your
appointment.
You will need to have the member’s name,
Medicaid ID number, home address, phone
number, where the member is to be picked up, the
name, phone number, and address of the health
care provider, the date and me of your
appointment, and general reason for the
appointment. Also, please let the operator know if
you have any special needs such as a wheelchair
accessible vehicle, assistance during the trip, or
someone to ride with you.
Eecve March 1, 2020
11 Eecve March 1, 2020
As of January 1, 2014, some individuals who receive
Medicaid services will be expected to pay co-
payments for certain services.
Exempt from the co-payment requirement are:
• Pregnant women, including pregnancy-related
services up to 60 days post-partum;
• Children under age 21; and
• Nave American and Alaska naves.
Services exempt from co-payment include:
• Long term care;
• Hospice;
• Medicaid Waiver;
• Breast and Cervical Cancer Treatment Program;
• Family planning; and
• Emergency services.
Co-payments are based on your level of income and
may not exceed 5% of your household income.
Providers may not deny services to individuals
whose household income falls below 100% of the
federal poverty level due to their inability to make a
co-payment.
Co-Payments
Service
Up to
50.00%
FPL
50.01-
100.00%
FPL
100.01%
FPL and
above
Inpaent Hospital (Acute Care) $0 $35 $75
Oce Visit (Physicians and Nurse Praconers) $0 $2 $4
Non-Emergency use of Emergency Department $8 $8 $8
Any outpaent surgical services rendered in a physician’s oce,
ambulatory surgical center or outpaent hospital excluding emergency
rooms
$0 $2 $4
Tier Level
Gross Quarterly Income Range for a
Household of 2
Out of Pocket Maximum
1 (Up to 50.00% FPL) $0 to $1,966 $8
2 (50.01-100.00% FPL) $1,967 to $3,932 $71
3 (100.01% FPL and above) $3,933 and above $143
Below is an example of the out-of-pocket maximum per quarter for a household of two people at the three
dierent er levels:
Below are the charts of co-payments:
Total Allowed Charge Co-payment
$0.00-$5.00 $0.00
$5.01-$10.00 $0.50
$10.01-$25.00 $1.00
$25.01-$50.00 $2.00
$50.01 and above $3.00
Pharmacy co-payments are the same for all Medical members regardless of income, however, out of pocket
maximums do apply:
12 Eecve March 1, 2020
Member Liability
• If you get a bill for medical care received in the
past 12 months for which you presented your
medical ID card, call the provider to see why,
then send that bill to:
Member Services
P.O. Box 2002
Charleston, WV 25327-2002
By Telephone: call 1-888-483-0797 or
304-348-3365
• If you have quesons about Medicaid coverage,
call Client Services at:
1-800-642-8589
304-558-2400
Hearing impaired: 304-558-3515
• If you have quesons about Managed Care call:
1-800-449-8466
• Services provided out-of-state must be
preapproved by Medicaid or Managed Care for
a medical emergency
Medicaid paents MUST PAY for:
• Services NOT covered by Medicaid
• Aer Medicaid benet is exhausted
• Not medically necessary
• Not approved by the Managed Care
provider (except for medical emergency)
• Convenience items not related to the
medical care
• Services provided when a paent is not
eligible
• Services from a provider who tells a paent
that he/she will not bill Medicaid before the
services is provided
• Services provided when the paent refuses
to use other private insurance
• Services provided when the paent does
not follow the plan provisions of their
primary insurance, which includes but is not
limited to ulizing in-network providers and
following all pre-cercaon guidelines
• Any Medicaid co-payments that apply to the
services the paent receives
Medicaid members must not be billed, or otherwise
held responsible for claims denied for provider
error.
For example:
• Claims led more than one year aer date of
services
• Wrongful billing or missing informaon
A directory of West Virginia Medicaid (fee-for-
service) Enrolled Providers can be found at DXC
Technology at hps://www.wvmmis.com
13 Eecve March 1, 2020
Your Medicaid Rights and Responsibilies
Discriminaon Prohibited
Medicaid benets will be extended in full
compliance with the 1964 Civil Rights Act, which
prohibits discriminatory administraon of benets
from federally funded programs because of sex,
race, color, religion, naonal origin, ancestry, age,
polical aliaon or physical/developmental/
mental challenges.
Medicaid does not discriminate on the basis of
disability in admission to or access to its programs
or in its operaons, services or acvies. If you have
quesons or complaints or if you want to talk about
whether you have a disability according to the
Americans with Disabilies Act (ADA), you may
contact the State ADA Coordinator at: WV
Department of Administraon, Building 1, Room
E-119, 1900 Kanawha Blvd., East, Charleston, WV
25305, or call (304) 558-4331, extension 57004.
Condenality
Any informaon obtained from you or concerning
you, including your Social Security Number (SSN),
shall be kept condenal. No informaon regarding
applicants or members shall be disclosed, without
consent, for any purpose other than those directly
concerned with administrave requirements. A copy
of the Medicaid Noce of Privacy Pracces is
provided at the end of this booklet.
Right to Appeal
You have the right to appeal if you are not sased
with the decision regarding your applicaon and/or
it is not handled within a reasonable period of me;
if you were not allowed to le an applicaon; or if
you think you were treated unfairly in any way.
Requests for appeals should be directed to your
local DHHR oce.
If you have received noce of a reducon,
suspension or terminaon of a Medicaid covered
service, you have a right to appeal that denial or
terminaon through the fair hearing process. The
noce that you receive will include an explanaon
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 relave, friend or other
spokesperson.
If you appeal prior to the date of terminaon of a
covered service, you may connue the service unl
a decision is made regarding your appeal. However,
if the state’s acon is upheld, the agency may start
recovery acons to recoup the cost of the services
furnished.
Services
You have the right to choose and/or make decisions
about health care for you and your children. You
may receive medical assistance for your child(ren),
including Early Periodic Screening, Diagnosis and
Treatment (EPSDT).
Upon request, you may receive informaon
regarding:
• Family planning services; and
• Domesc violence services.
You may be qualied to apply for low-priced
telephone services called Tel-Assistance/Lifeline
that the telephone company in your area oers.
With your permission, DHHR may release
informaon to the telephone company concerning
your eligibility for this service. If your eligibility for
Medicaid is stopped, DHHR will nofy the telephone
company.
Right to Informaon
You have the right to see your medical records and
ask quesons about health care.
You have the right to be treated fairly and with
respect.
You have the right to know the laws and rules of the
Medicaid Program and to ask quesons about your
plan.
Changes Aecng Eligibility
You must nofy DHHR of the following within 10
days if:
• Your address, name, or telephone number
changes;
• Anyone in your household obtains/loses
employment or there are changes in your
household income;
14 Eecve March 1, 2020
• There are changes in your household’s amount
or source of unearned income;
• Anyone moves into/out of your household;
• There are changes in your household assets,
including receiving, selling, purchasing, or losing
a vehicle, including recreaonal vehicles and
equipment;
• Anyone in your household receives a lump sum
payment; and/or
• You are involved in an accident which results in
a selement either in or out of court.
Repayment of Benets
Certain federal and state laws require Medicaid
members to make repayments for benets received
if:
• Unintenonal errors were made by you or by
DHHR, which resulted in your receiving benets
for which you were ineligible; and/or
• You or any person in your household receiving
Medicaid receive payment from an insurance
company, with or without a court order, for
medical and/or hospital bills for which Medicaid
has or will make payment. This includes
insurance selements resulng from an
accident.
You must cooperate with DHHR and any provider of
medical services in pursuing any resources available
to meet the medical expenses resulng from an
injury or an accident.
Fraud
Any person who obtains or aempts to obtain
benets from Medicaid by means of a willfully false
statement or misrepresentaon or by
impersonaon or any other fraudulent device, can
be charged with fraud. Punishment upon a
convicon may be a ne up to $5,000 and/or a jail
sentence of ve years in a state correconal facility.
Medicaid members receiving long-term care services have these addional rights
and responsibilies:
A period of ineligibility for Medicaid long-term care
may result if resources, including certain trusts,
were transferred within the 60-month period prior
to the date of applicaon.
You must disclose to the state any interest you or
your spouse have in an annuity. The state must be
named as the remainder beneciary or as the
second remainder beneciary aer a spouse or a
minor or disabled child, for an amount at least
equal to the amount of Medicaid benets provided.
Aer June 9, 1995, any Medicaid funds paid on
behalf of individuals age 55 or older for long-term
care services and related hospital and prescripon
drug services must be recovered. For more
informaon regarding Estate Recovery call
(304) 342-1604.
If you are in a nursing home, you must nofy your
county DHHR oce within 10 days if:
• You are discharged from a nursing or
intermediate care facility to go to another
facility or return home;
• There are changes in your gross unearned or
earned income or the income of your spouse
and any dependent children who live with your
spouse; and/or
• There are changes in your assets or those of
your spouse, including receiving, selling,
purchasing or giving away assets.
15 Eecve March 1, 2020
Noce of Privacy Pracces
Eecve date of this noce: April 14, 2003
If you have quesons about this noce, please contact Client Services at 1-800-642-8589 or the Privacy
Ocer at the address or phone listed on page 16.
This noce describes how medical informaon about you may be used and disclosed and how you can get
access to this informaon. Please review it carefully.
PRIVACY AND YOU
Your health informaon is personal and private. The West Virginia Medicaid Program must keep your health
informaon private. Your doctors, densts, clinics, labs, and hospitals send informaon to us when they ask
us to approve and pay for your health care. We must give you this Noce of the law of how we keep your
health informaon private.
CHANGES TO NOTICE OF PRIVACY PRACTICES
All Medicaid employees, sta, students, volunteers, and other personnel whose work is under direct control
of Medicaid must obey the rules in this noce. We have the right to change our privacy pracces. If we do
make changes, we will send a new Noce right away to all people covered by Medicaid. We are required to
provide this Noce of our privacy pracces and legal dues regarding health informaon 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 informaon, such as your name,
address, personal facts, the medical care you had and your medical records. Any informaon shared must
be for a reason related to the administraon of the Medicaid program. Such reasons include:
• To approve eligibility for medical and dental benets
• To establish ways to pay for health care
• To approve, provide, and pay for Medicaid health care
• To invesgate 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, denst, clinic, or other
health care provider. We will share informaon with necessary providers to make sure you get the care
you need. For instance, we may use your health records to idenfy if you need special informaon
about a health problem like diabetes.
2. For payment: When Medicaid pays your health care bills, we share informaon 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 operaons: We may use your health records to check the quality of the health care you
receive. We may also use them in audits, fraud and abuse programs, planning, and managing the
Medicaid Program. For instance, your prescripons are reviewed to ensure the medicines can be used
together without harm to you.
4. For health noces: We may use your health records to provide you with addional informaon. This
may include sending appointment reminders to your address, giving you informaon about treatment
opons, alternave sengs for care, or other health-related services.
16 Eecve March 1, 2020
5. For legal reasons: We may give your informaon to a court, invesgator, or lawyer in cases about
Medicaid. This may be about fraud or abuse, to get back money from others who should pay your
Medicaid bills, or other issues related to the Medicaid Program. If a court orders us to give out your
informaon, we will do so.
6. To report abuse: We may disclose your health informaon when the informaon relates to a vicm of
abuse, neglect, or domesc violence. We will make this report only in accordance with laws that require
or allow such reporng, or with your permission.
7. Public health acvies: We will disclose your health informaon when required to do so for public
health purposes. This includes reporng certain diseases, births, deaths, and reacons to certain
medicaons. It may also include nofying people who have been exposed to a disease.
8. Research: We may disclose your health informaon in connecon with medical research projects.
Federal rules govern any disclosure of your health informaon 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 informaon may be used to decide these appeals.
10. For eligibility: We may share your informaon with federal, state, and local agencies when you apply for
Medicaid to verify eligibility, and for other purposes related to the administraon of the Medicaid
Program.
An electronic signature has the same legal eect and can be enforced in the same way as a wrien signature.
WRITTEN PERMISSION
Medicaid may use or share your informaon in limited ways. If we want to use your health informaon in a
way not listed above, we must get your permission in wring. If you give permission, you may withdraw it in
wring at any me.
WHAT ARE MY PRIVACY RIGHTS?
You have the right to:
• Ask us to restrict how we use or disclose your health informaon. The request must be in wring. We
may not be able to comply with your request if we have already used your authorizaon, if the
informaon 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 informaon. A personal representave who has the legal right to
act for you may look at and get it for you. We have informaon 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
ll 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 informaon in your records if it is not correct or complete. We may refuse to change the
informaon 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 leer to disagree with the denial. This leer will be kept with
your Medicaid records.
• Ask us for a report of informaon shared about you for reasons other than treatment, payment, or
Medicaid operaons. You may ask for a list of those with whom we shared your informaon, when, why,
and what informaon was shared. The list will start on April 14, 2003.
• Ask us to send your informaon somewhere. You will be asked to sign an authorizaon form to tell us
what informaon to send and where it is to go. The authorizaon can be used for up to one year, but you
may tell us a specic me. You may write to stop the authorizaon at any me.
• Ask for a paper copy of this Noce of Privacy Pracces. You can also nd this Noce on our website at:
hp://www.dhhr.wv.gov/bms/Members/Pages/Noce-of-Privacy-Pracces.aspx.
17 Eecve March 1, 2020
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, denst, clinic, or health plan. If you are in a Managed Care
plan, that plan may have informaon about bills paid for you aer 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 Noce, 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 Ocer
Bureau for Medical Services
350 Capitol Street, Room 251
Charleston, West Virginia 25301-3709
Phone: (304) 558-1700 or Fax: (304) 558-4397
Privacy Ocer
West Virginia Department of Health and Human Resources
1 Davis Square, Suite 100 East
Charleston, West Virginia 25301
Phone: (304) 558-0684 or Fax: (304) 558-1130
Secretary of the U. S. Department of Health and Human Services
Oce for Civil Rights
Aenon Regional Manager
150 So. Independence Mall West, Suite 372
Philadelphia, PA 19106-3499
NO RETALIATION
Medicaid cannot take away your health care benets or retaliate in any way if you le a complaint or use any
of the privacy rights in this Noce.
QUESTIONS
If you have quesons about this noce and want more informaon, please contact the Privacy Ocer at the
West Virginia Department of Health and Human Resources, Bureau for Medical Services by phone at (304)
558-1700 or by fax at (304) 558-4397.
Copies of this noce are available at local county oces of the West Virginia Department of Health and
Human Resources. This noce is available by e-mail. Contact the Bureau for Medical Services at the above
locaon. This noce is also available on the web at: hp://www.dhhr.wv.gov/bms/Members/Pages/Noce-of
-Privacy-Pracces.aspx.
18 Eecve March 1, 2020
Mountain Health Trust is the West Virginia Medicaid
Managed Care Program. A Managed Care
Organizaon (MCO) is a health care company that
contracts with various health care providers to
provide members with quality and cost-eecve
health care.
Individuals who are required to sign up with an
MCO will receive a packet in the mail explaining
their choices. If you receive such a packet, you must
choose one of three MCOs. If you do not choose an
MCO, one will be chosen for you. The MCO you
choose will ask you to pick a primary care provider
(PCP) who will handle most of your medical needs.
If you need a specialist or hospital care, your PCP
will set that up for you.
Currently, the only services not covered by the
MCOs are aboron services, school-based services,
transplant services, long-term care, waiver, personal
care, pharmacy, and non-emergency medical
transportaon. If you require one or more of these
services, contact your MCO for more informaon.
As of July 1, 2017, pharmacy services are paid by the
tradional Medicaid fee-for-service program.
When you are enrolled in an MCO, you will receive a
medical card from the MCO as well as a medical
card from DHHR. You must take both cards to all of
your appointments.
The MCOs for West Virginia are:
• Aetna Beer Health of WV (formerly Coventry
Cares of WV)
• 1-888-348-2922
• TTY: 711
• www.aetnabeerhealth.com/
westvirginia
• The Health Plan
• 1-888-613-8385
• TTY: 1-800-622-3925
• www.HealthPlan.org
• UniCare
• 1-800-782-0095
• TTY: 1-800-982-8771
• hp://mss.unicare.com/
Mountain Health Trust - Managed Care
19 Eecve March 1, 2020
If you have Medicaid and you belong to an MCO, you
have the right to request the following at least once
a year by calling 1-800-449-8466:
• A directory of all current contracted providers
including:
• Names/addresses/telephone numbers;
• Languages other than English;
• Closed or open pracce; and
• Primary care/specialist/hospital.
• Instrucons on how to use the directory:
• Your choice of provider;
• Referral process for specialty care; and
• Explanaon of network.
• Informaon on grievance and fair hearing
procedures and the me frame.
• Services which connue to be accessed under
fee-for-service including:
• Some family-planning services;
• Non-emergency medical transportaon; and
• Long-term care/nursing homes.
• Informaon on:
• How to obtain benets;
• Non-covered services;
• Aer-hours access;
• Advanced Direcves or a “living will” that
allows someone else to make medical
decisions for you if you are unable to make
your own decision; and
• How doctors are paid.
• A copy of your rights and responsibilies:
• You also have the right to go to the nearest
emergency room or call 911 in cases of
emergency. Prior authorizaon is not
required for emergencies.
Medicaid Managed Care Consumer Rights
Important Telephone Numbers
To nd your local DHHR Oce ....................................................... 1-877-716-1212
DHHR Client Services ...................................................................... 1-800-642-8589
Medically Frail Form ....................................................................... 1-888-483-0797
Quesons regarding payments to medical provider
DXC Technology .............................................................................. 1-888-483-0797
Quesons regarding your Managed Care coverage,
change your primary care provider, etc. ........................................ 1-800-449-8466
Medical Emergency ......................................................................... 911
Your Local DHHR Oce .................................................................. __________________
Your Doctor……………………………………………………... .......................... __________________
Your Denst…………………………. ....................................................... __________________
Your Child(ren)’s Doctor ................................................................ __________________