WV.gov
Agency Header

CoPay Information

Beginning January 1, 2014, some services will be assigned copay amounts for Medicaid
Members. The following copays will apply to claims with a date of service on or after
January 1, 2014.
Providers can access copay and member eligibility information through AVRS by
calling (888)-483-0793 or by visiting
www.wvmmis.com.
 


 Service

Tier 1
Up to 50.00%
FPL

Tier 2
50.01%-100.00%
FFL

Tier 3
100.00% & Above
FPL

 Inpatient Hospital (Acute Care 11x)

  $0

$35

$75

 Office Visit (Physicians and Nurse
 Practioners-99201-99205,
 9921299215: Only for office visits
 established patients based on
 level of care)

 
 $0

 
$2

 
$4

 Non-Preferred Drugs

$2

$4

$8

 Non-Emergency use of Emergency
 Hospital Only: Lowest level (99281)
 of Emergency Rm visits in hospitals.
 The definition of this visit is an
 emergency department visit for the
 evaluation management of a patient,
 which requires 3 key components:
 A problem focused history; 
 A problem focused examination;
 And straightforward medical decision
 making)

 


$8

 


$8

 


$8

 Any outpatient surgical services
 rendered in a physician's office, ASC,
 or Outpatient Hospital excluding
 emergency rooms

 

$0

 

$2

 

$4

Molina will return a copay amount for the start date of service if the provider inquires on a date range. No copays will be listed for members on the exemption list. Remittance advices will be modified to include the copay amount that was deducted.

Maximum Out of Pocket (OOP):

Each calendar year quarter, Members will have a maximum out of pocket (OOP) payment. The OOP is the most the Member will ever be required to pay in any given quarter regardless of the number of healthcare services received. The following table shows the OOP for each tier level.

Tier Level

Out of Pocket Maximum

1. (Up to 50.00% FPL)

$8

2. (50.01-100.00% FPL)

$71

3. (100.01% FPL and above)

$143

 

Quarters
January 1 – March 31, 2014
April 1 – June 30, 2014
July 1 – September 30, 2014
October 1 – December 31, 2014

Exemptions:
The following populations and services are exempt from copays: 

  • Pregnant Women including pregnancy-related services up to 60 days post-partum;
  • Children under age 21; 
  • Native American and Alaska natives; 
  • Intermediate Care Facility or MR services; 
  • Preventive services for children under age 18; 
  • Provider-preventable services; 
  • Individuals in Nursing Homes, 
  • Receiving Hospice services, 
  • Medicaid Waiver services, or covered through the Breast and Cervical Cancer Treatment Program; 
  • Family Planning services and Emergency services.
Additional exemptions for Pharmacy include diabetic testing supplies syringes and needles, BMS approved Home Infusion supplies and 3-day emergency supplies.