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Division of Policy and Coordination

The Division of Policy Coordination is headed by Acting Deputy Commissioner Sarah Young who is responsible for the development of Medicaid health care coverage, policy and utilization management of all Medicaid benefit programs including; practitioner services, behavioral health and long-term care services, pharmaceutical services, hospital and outpatient clinic services, rehabilitative services, home and community based services, school based services, and transportation.  Areas of responsibility include:
  • The Medical Director provides medical expertise to BMS professional staff.  Primary activities include: clinical research for policy development, clinical representation of the Medicaid program with external organizations or other governmental departments, clinical research of best medical practices, physician reviewer of medical necessity, prior authorization and denied services appeals, and participates on various committees, associations and boards as a representative of West Virginia Medicaid.  Medical Director is Dr. James B. Becker.
     
  • The Office of Facility and Residential Care is responsible for developing, implementing and managing the medical assistance coverage and utilization policies for inpatient hospital, FQHC, facility based services such as Nursing Homes and ICF/MR facilities, and residential services such as Psychiatric Residential Treatment Facilities and Children’s Residential Facilities.  Directed by Sarah Young.  

  • The Office of Professional Services is responsible for developing, implementing and managing the State’s medical assistance coverage and utilization policies for the following services:  Out-Patient Services, Practitioner Services, Durable Medical Equipment, Orthotics & Prosthetics, Laboratory, Radiology, Transportation, Podiatry, Chiropractic, Dental, Vision, Occupational/Physical Therapy, and Speech.  Directed Vacant.  

  • The Office of Home & Community Based Services is responsible for developing, implementing and managing the State’s medical assistance coverage and utilization policies for the following programs:  Home Health, Hospice, A/D Waiver, MR/DD Waiver, Personal Care, CDCSP, Targeted Case Management, Behavioral health clinic and rehab, Psychological and psychiatric services ad school based health services.  Directed by Pat Nisbet.
     
  • The Office of Policy and Administrative Services is responsible for the development, coordination and maintenance of the West Virginia Medicaid Program Provider Manuals.   In addition to overseeing the distribution of policy, the office is responsible for provider enrollment policy and oversight, WV Clearance for Access: Registries and Employment Screening Program, ICD 10 compliance, National Correct Coding initiative, and procedure code implementation. Directed by Tanya Cyrus.

  • The Office of Pharmacy Services establishes coverage and reimbursement policies for outpatient medications within federal guidelines.  Included within the program responsibilities are the federally-mandated prospective and retrospective drug utilization review activities; prior authorization of high-cost, high-risk, drugs and maintenance of a Preferred Drug list.  Drug coverage is provided to all Medicaid covered eligibility groups, including recipients enrolled in managed care organizations.  Directed by Vicki M. Cunningham.
  • The Office of Managed Care is responsible for the administration and oversight of a risk-based managed care program, Mountain Health Trust and the Physician Access System (PAAS), both of which operate under an approved 1915(b) waiver. The Bureau contracts with four managed care organizations for the provision of medically necessary services for approximately 170,000 Medicaid members.  PAAS is designed to enhance access to medical care and to coordinate the health needs and services of the Medicaid recipient, while managing cost and ensuring quality care. Directed by Brandy Spaulding.
  • The Office of Special Projects is responsible for the development, management and implementation of projects within the Bureau which requires vital input from key stakeholders. The office is responsible for ensuring Medicaid members, providers, stakeholders and the public are kept informed about about the activities of the Bureau. Project management is key component of this office. Directed by Penney Hall.

  • Take Me Home, WV, is a federally funded Money Follows the Person Rebalancing Demonstration Grant Program which assists elderly and individuals with disabilities move from a long-term care setting to a home in the community. This program allows Medicaid to pay for services and supports which are not typically covered by Medicaid. In addition, participants can receive extended direct care services such as extra hours of personal care through one of the waiver programs or the Personal Care Program.  Directed by Marcus Canaday.
  •  Office of Transportation is responsible for the oversight of the Bureau's emergency and non-emergency medical transportation services, including monitoring of the NEMT broker.  Directed by Tammy Pritt-Jones.

     

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