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Services Covered By Medicaid

Medical Services Covered by Medicaid
  • Physicians' services

  •  Hospital inpatient care

  • Outpatient hospital services

  • Emergency room services

  • X-ray and laboratory services prescribed by an authorized practitioner

  • Routine dental care for children and with approval, some medically necessary special care such as braces.  Adult dental coverage is limited to removal of cysts or tumors, biopsies, treatment of fractures of the jaw bones and some emergency services

  • Prescribed drugs.  Most of the drugs that are proscribed by your doctor are covered by the Medicaid Program.  Drugs sold over-the-counter must be prescribed by your doctor to be covered.  Some drugs have limits and some may require prior approval.
    The Medicaid Pharmacy Program does have a Preferred Drug List (PDL).  Your doctor and pharmacist have copies of this list.  If the drug that is prescribed for you is not on the list, a prior approval will be required.  In most cases, the drug prescribed or a substitute (approved by your doctor) from the list, can be given to you while you are in the pharmacy.  If not, a three-day emergency supply of your prescription is always available to you.  You should never leave the pharmacy without some of your medicine.  As soon as the approval is give, you will be able to get the rest of your prescription.  You should show your Medicaid card to your pharmacist each time you have a prescription filled.  You will be asked to pay a co-pay for each prescription.  Children and pregnant women do not have to make this co-payment.  It is best to have all of your prescriptions filled at the same pharmacy.  By doing this, your pharmacist and doctors can make sure that your prescriptions work together for you.

  • Transportation to medical facilities by ambulance or other most appropriate means

  • Artificial limbs, braces, orthopedic shoes, crutches, walkers, wheelchairs, and breathing machines, when prescribed by a doctor.

  • Eye care services.  Comprehensive vision care services are covered for children through age 20.  Adult coverage is limited to one pair of eyeglasses following cataract surgery.

  • Care in nursing facilities

  • Family planning services

  • Outpatient mental health services

  • Early and Periodic Screening; Diagnosis and Treatment (EPSDT) for children aged 0-20 years.

This does not include all medical services you can receive through the Medicaid Program.  Some types of medical care you may need will require prior approval from the West Virginia Department of Health and Human Resources

Note:  The West Virginia Department of Health and Human Resources does place certain limitations of the extent of services that can be provided and the fees that will be paid.

Persons eligible for the Medicaid Program obtain medical services by presenting their cards to participating physicians, hospitals, pharmacies or other providers of medical services.  The medical service provider then bills the West Virginia Department of Health and Human Resources for payment.

Out-Of-State Medicaid Coverage
Only the following types of medical services received outside the State of West Virginia are covered under the Medicaid Program:

    1. Emergency treatment that is received while traveling or visiting out of state, or
    2. Treatment received after prior approval from WV DHHR. The referring physician must request prior approval. 

Out-of State services are usually not approved if they are available in West Virginia.  All out-of state providers will have their claims denied for non-emergency medical services unless:

    1. They have been declared a border provider.  Certain medical provider practicing within 30 miles of West Virginia 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.
    2. The services have been prior approved.

If you move from the State of West Virginia, go to that state's nearest Health and Human Resources office and ask to apply for Medicaid.  West Virginia's Medicaid Program pays only for people who live in West Virginia.


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