Agency Header

WV State Medicaid Plan

 Complete State Plan
updated 3/15
   Click Here To Download Adobe Reader  Adobe Reader is Required
 Table of Contents
 

 Sections
  New   S10 MAGI Based Methodologies  
  New  S88 Residency Requirements  
  New  S89 Non-Financial Eligibility Requirements  
  New  S94 General Eligibility Process  
  New     • Attachment 1 Single State Streamline Application  
  New     • Attachment 2 On-line Application  
 

1.0          

SINGLE STATE AGENCY ORGANIZATION UNIT  
  1.1      Designation and Authority
  1.2      Organization for Administration
    1.3      Statewide Operation  
    1.4      State Medical Care Advisory Committee  
    1.5      Pediatric Immunization Program  
       
  2.0 COVERAGE AND ELIGIBILITY  
 New   2.1      Application, Determination of Eligibility and Furnishing Medicaid  
    2.2      Coverage and Conditions of Eligibility  
    2.3      Residence  
    2.4      Blindness  
    2.5      Disability  
    2.6      Financial Eligibility  
    2.7      Medicaid Furnished Out of State  
       
  3.0 SERVICES: GENERAL PROVISIONS   
    3.1      Amount, Duration, and Scope of Services  
    3.2      Coordination of Medicaid with Medicare and Other Insurance  
    3.3      Medicaid for Individuals Age 65 or Over in Institutions for Mental Diseases  
    3.4      Special Requirements Applicable to Sterilization Procedures  
    3.5      Families Receiving Extended Medicaid Benefits  
    3.7      Services to Families Receiving Extended Medicaid Benefits (Continued)  
     
  4.0 GENERAL PROGRAM ADMINISTRATION  
    4.1      Methods of Administration  
    4.2      Hearings for Applicants and Recipients  
    4.3      Safeguarding Information on Applicants and Recipients  
    4.4      Medicaid Quality Control  
    4.5      Medicaid Agency Fraud Detection and Investigation Program  
    4.6      Reports  
    4.7      Maintenance of Records  
    4.8      Availability of Agency Program Manuals  
    4.9      Reporting Provider Payments to Internal Revenue Service  
    4.10    Free Choice of Providers  
    4.11    Relations with Standard-Setting and Survey Agencies  
    4.12    Consultation to Medical Facilities  
    4.13    Required Provider Agreement  
    4.14    Utilization/Quality Control  
    4.15    Inspection of Care in Intermediate Care Facilities for Mentally Retarded, Facilities Providing Inpatient Psychiatric Services for Individuals Under 21, and Mental Health Hospitals  
    4.16    Relations with State Health and Vocational Rehabilitation Agencies and Title V Grantees  
Updated   4.17    Liens and Adjustments and Recoveries  
    4.18    Recipient Cost Sharing and Similar Charges  
    4.19    Payment for Services  
    4.20    Direct Payments to Certain Recipients for Physicians' or Dentists' Services  
    4.21    Prohibition Against Reassignment of Provider Claims  
    4.22    Third Party Liability  
    4.23    Use of Contracts  
    4.24   Standards for Payments for Nursing Facility and Intermediate Care Facility for the Mentally Retarded Services  
    4.25    Program for Licensing Administrators of Nursing Homes  
    4.26    Drug Utilization Review Program  
    4.27    Disclosure of Survey Information and Provider or Contractor Evaluation  
    4.28    Appeals Process  
    4.29    Conflict of Interest Provisions  
    4.30    Exclusion of Providers and Suspension of Practitioners and Other Individuals  
    4.31    Disclosure of Information by Providers and Fiscal Agents  
    4.32    Income and Eligibility Verification System  
    4.33    Medicaid Eligibility Cards for Homeless Individuals  
    4.34    Systematic Alien Verification for Entitlements  
    4.35    Enforcement of Compliance for Nursing Facilities  
    4.36    Required Coordination Between the Medicaid and WICK Programs  
    4.38    Nurse Aide Training and Competency Evaluation for Nursing Facilities  
    4.39    Preadmission Screening and Annual Resident Review in Nursing Facilities  
    4.41    Resident Assessment for Nursing Facilities  
    4.42    Employee Education About False Claims Recoveries  
     
  5.0  PERSONNEL ADMINISTRATION  
    5.1    Standards of Personnel Administration  
    5.2    (Reserved)  
    5.3    Training Programs; Sub professional and Volunteer Programs  
       
  6.0      FINANCIAL ADMINISTRATION  
    6.1    Fiscal Policies and Accountability  
    6.2    Cost Allocation  
    6.3    State Financial Participation  
       
  7.0 GENERAL PROVISIONS  
    7.1    Plan Amendments  
    7.2    Nondiscrimination  
    7.3    Maintenance of AFDC Effort  
    7.4    State Governor's Review  
       
  Attachments and Supplements  
  1.1-A Attorney General's Certification  
  1.2-A Organization for Administration  
  1.2-B Organization for Administration  
  1.2-C Organization for Staffing  
  1.2-D Organization for Administration   
  2.1-A Health Maintenance Organization   
Updated 2.2-A Groups Covered and Agencies Responsible For Eligibility Determination  
Updated        •  Pages 1-9b2 - Mandatory Coverage - Categorically Needy and Other Required Special Groups  
Updated       •  Pages 9c-23d - Optional Groups Other than the Medically Needy  
Updated       •  Pages 24-26a - Optional Coverage of the Medically Needy  
        •  Page 27 -Requirements Relating to Determining Eligibility for Medicare Prescription Drug Low-Income Subsidies  
        •  Supplement 1 - Reasonable Classification of Individuals Under the Ages of 21, 20, 19, and 18  
        •  Supplement 3 - Method for Determining Cost Effectiveness of Caring for Certain Disabled Children at Home  
Updated 2.6-A Eligibility Conditions and Requirements  
Updated        •  Pages 1-3c - General Conditions of Eligibility  
        •  Pages 4-5a - Post Eligibility Treatment of Institutionalized Individuals  
Updated       •  Pages 6-26 - Financial Eligibility  
        •  Supplement 1 - Income Eligibility Levels  
        •  Supplement 1a - Income Eligibility Levels - Categorically Needy  
Updated       •  Supplement 2 - Resource Levels  
        •  Supplement 3 - Reasonable Limits on Amounts for Necessary Medical or Remedial Care Not Covered Under Medicaid  
        •  Supplement 5 - More Restrictive Methods of Treating Resources with Income Related to the SSI Program  
        •  Supplement 5a - Methods of Treating Resources for Individuals with Incomes Related to Federal Poverty Levels  
        •  Supplement 6 - Standards for Optional State Supplementary Payments  
        •  Supplement 7 -  Income Levels for 1902 (f) States - Categorically Needy Who re Covered Under Requirements More Restrictive than SSI  
        •  Supplement 8 - Resource Standards for 1902 (f) States - Categorically Needy  
Updated       •  Supplement 8a - More Liberal Methods of Treating Income Under Section 1902 (r)(2) of the Act  
Updated       •  Supplement 8b - More Liberal Methods of Treating Resources Under Section 1902 (r)(2) of the Act  
 New       • Supplement 8c - State Long-Term Care Insurance Partnership  
        •  Supplement 9 -  Transfer of Resources  
        •  Supplement 9a - Transfer of Assets  
        •  Supplement 9b - Transfer of Assets for Less Than Fair Market Value Made on or After February 8, 2006  
        •  Supplement 10 - Consideration of Medicaid Qualifying Trusts - Undue Hardship  
        •  Supplement 11 - Cost Effectiveness Methodology for Cobra Continuation 
       Beneficiaries
 
        •  Supplement 12 - Eligibility Under Section 1931 of the Act  
        •  Supplement 13 - Spousal Impoverishment - Undue Hardship  
        •  Supplement 17 - Home Equity  
New       • Supplement 18 -Methodology for Identification of Applicable FMAP Rates  
New  3.1     • Attachment 2 - WV Medicaid Redesign Benefit Package  
Updated 3.1-A  Amount, Duration and Scope of Medical and Remedial Care and Services Provided to the Categorically Needy  
        •  Supplement 1 - Case Management Services  
        • Attachment for A, D, and E of Supplement 1 to Attachment 3.1-A  
New       • Addendum - School-Based Health Services (Special Education)  
  3.1-B Amount, Duration and Scope of Services Provided for Medically Needy Group(s): All Covered Medically Needy Groups  
New 3.1-A & 3.1-B Amount, Duration, Scope of Medical and Remedial Care And Services Provided to the Medically Needy - Methods of Providing Transportation  
    Supplement 2 to Attachments 3.1A and 3.1B Amount, Duration and Scope of Assistance  
  3.1-C Alternative Benefits Benchmark Equivalent Quality Package  
Updated 3.1-D Methods of Providing Transportation  
  3.1-E Standards for the Coverage of Organ Transplant Procedures  
New  3.1-H Health Home  
  3.1-L Alternative Benefit Plan  
  3.2-A Coordination of Title XIX with Part A and Part B of Title XVIII  
  4.5  Recovery Audit Contractor  
  4.11-A Standards for Institutions  
  4.16-A Interrelationships with State Health and State Vocational Rehabilitation Agencies and with Title V Grantees  
  4.17-A Liens and Adjustments or Recoveries  
  4.18-A Charges Imposed on Categorically Needy for Services Other Than Those Provided Under Section 1905 (a) (1)  
  4.18-C Charges Imposes on the Medically Need for Services Other Than Those Provided Under Section 1905 (a) (1) through (5) and (7) Act  
Updated 4.19-A Inpatient Hospital Services  
        •  Supplement 1 - Transition Percentage for Operating Payments  
Updated       • Supplement 2 - Transition Percentage for Capitol Payment Amounts  
  4.19-A-1 Payments for Medical and Remedial Care and Services-Inpatient Hospitals Services - Disproportionate Share Hospitals    
  4.19-A-2 Payment for Medical and Remedial Care and Services-Inpatient Psychiatric Facility Services for Individual Under 22 Years of Age  
Updated   4.19-B Payments for Medical and Remedial Care and Services  
        •  Supplement 1 - Methods and Standards for Establishing Payment Rates-Other Types of Care  
      • Supplement 2 - Payment Adjustment for Other Provider Preventable Conditions    
  4.19-D Methods and Standards for Determining Payment Rates for State-Owned Long Term Care Facilities (SNF, ICF, and ICF/MR Facilities)  
  4.19-D-1 Methods and Standards for Determining Payment Rates for Non-State-Owned Nursing Facilities Excludes State-Owned Facilities  
  4.19-D-2 Methods and Standards for Determining Payment Rates for  Intermediate Care Facilities for Mentally Retarded  
  4.19-E Timely-Claims Payment  
  4.22-A Requirements for Third Party Liability - Identifying Liable Resources  
  4.22-B Requirements for Third Party Liability - Payment of Claims  
  4.22-C State Method on Cost Effectiveness of Employer-Base Group Health Plans  
  4.30 Sanctions for MCOs and PCCMs  
  4.32-A Income and Eligibility Verification System Procedures: Requests to Other State Agencies  
  4.33-A Method for Issuance of Medicaid Eligibility Cards to Homeless Individuals  
  4.34-A Requirements for Advance Directives Under State Plans for Medical Assistance  
  4.35-A Eligibility Conditions and Requirements-Enforcement of Compliance for Nursing Facilities  
  4.35-B Eligibility Conditions and Requirements-Termination of Provider Agreement  
  4.35-C Eligibility Conditions and Requirements-Temporary Management  
  4.35-D Eligibility Conditions and Requirements-Denial of Payment for New Admission  
  4.35-E Eligibility Conditions and Requirements-Civil Money Penalty  
  4.35-F Eligibility Conditions and Requirements-State Monitoring  
  4.35-G Eligibility Conditions and Requirements-Transfer for Residents with Closure of Facility  
  4.35-H Eligibility Conditions and Requirements-Additional Remedies  
  4.38 Disclosure of Additional Registry Information  
  4.38-A Collection of Additional Registry Information  
  4.39 Definition of Specialized Services  
  4.39-A Categorical Determinations  
  4.42-A False Claims Act Attachment  
  4.43-A Medicaid Integrity Program Efforts  
  4.44 Prohibition on Payments to Entities Outside the US  
  4.46  Provider Screening and Enrollment    
  5.1-A Standards of Personnel Administration  
  7.2-A Nondiscrimination  
New  S14 AFDC Income Standards  
New S21   Presumptive Eligibility by Hospitals  
    Eligibility Groups - Mandatory  
New  S25 Parents and Other Caretaker Relatives  
New S28 Pregnant Women  
New S30 Infants and Children Under Age 19  
New S32 Adult Group  
New S33 Former Foster Care Children  
  Eligibility Groups - Optional Coverage  
New S50 Individuals above 133% of FPL  
New S51 Optional Coverage of Parents and Other Caretaker Relatives  
New S53 Children With Non-IV-E Adoption Assistance  
New  S54 Optional Targeted Low Income Children  
New S55 Individuals With Tuberculosis  
New  S57 Independent Foster Care Adolescents  
New S59 Individuals Eligible for Family Planning Services  









































































































Follow us on Facebook