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Acute Care Services
Long-Term Care Services


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Benefits by State: West Virginia (October 2008) Notes
 
 
 
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Acute Care Services

Is the Benefit Covered? Copayment Requirement Prior Approval Requirement Coverage Limitations Reimbursement Methodology Populations Covered


Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes Fee for service using a percentage of Medicare allowable payment as ceiling A & B
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes Specified procedures A - substance abuse treatment not covered, B - 20 substance abuse treatment visits/year Fee for service A & B
Federally Qualified Health Center Services
Yes Prospective cost based rate/visit A & B
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes Non-emergency admissions except maternity A & B - inpatient rehab admissions not covered, A - inpatient psych admissions not covered, B - inpatient psych limited to 30 days/year Prospective payment/discharge using DRG and urban/rural adjustment, adjusted rate for sole community hospitals, negotiated rates for transplant services A & B
Outpatient Hospital Services
Yes Specified surgical procedures and other services Fee for service A & B
Rehabilitation Services: Mental Health and Substance Abuse
Yes Specified procedures B - 20 visits/year Fee for service B
Rural Health Clinic Services
Yes Prospective cost based rate/visit A & B
Practitioner Services
Certified Registered Nurse Anesthetist Services
Yes Fee for service A & B
Chiropractor Services
Yes Yes Fee for service B
Dental Services
Yes Restorative services or item replacement Limited to trauma care including maxillofacial surgery and to emergency treatment for relief of pain and infection Fee for service A & B
Medical and Remedial Care - Other Practitioners
Medical/Surgical Services of a Dentist
Yes Limited to trauma care including maxillofacial surgery and emergency treatment for relief of pain and infection Fee for service A & B
Nurse Midwife Services
Yes Fee for service A & B
Nurse Practitioner Services
Yes Fee for service A & B
Optometrist Services
Yes 1 refractive exam/3 years Fee for service A & B
Physician Services
Yes Specified surgical procedures Fee for service A & B
Podiatrist Services
Yes Specified services and appliances Fee for service B
Psychologist Services
Yes Yes Fee for service A & B
Prescription Drugs
Prescription Drugs
Yes $.50-$3/Rx depending on drug cost Specified drugs including vitamins, acute dosing of anti-ulcer drugs beyond 90 days and amphetamines A - 4 Rxs/month, specified over the counter products covered AWP-30%, plus $5.30 dispensing fee for generic Rx; AWP-15%, plus $2.50 dispensing fee for brand Rx; $1.00 more for compound Rxs A & B
Physical Therapy and Other Services
Occupational Therapy Services
Yes Yes A - 20 visits/year in combination with other therapies Fee for service A & B
Physical Therapy Services
Yes A - 20 visits/year in combination with other therapies Fee for service A & B
Services for Speech, Hearing and Language Disorders
Yes Yes A - 20 visits/year in combination with other therapies Fee for service A & B
Products and Devices
Dentures
No
Eyeglasses
Yes Specified items and services 1 pair eyeglasses following cataract surgery Fee for service A & B
Hearing Aids
No
Medical Equipment and Supplies
Yes Yes A - $1,000/year Fee for service A & B
Prosthetic and Orthotic Devices
Yes Specified services Fee for service A & B
Transportation Services
Ambulance Services
Yes Fee for service, using Medicare payment ceilings CN & MN
Non-Emergency Medical Transportation Services
Yes Yes A - 10 one-way trips/year See service-specific FN A & B
Other Services
Diagnostic, Screening and Preventive Services
No
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women
Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes Fee for service, and using a percentage of Medicare payment ceilings for lab services A & B
Targeted Case Management
Yes Yes Prospective cost based rate A & B


Long-Term Care Services

Community Based Care
Home and Community Based Services Waiver
Yes Services for the following populations: 2, 4 & 8 - See service-specific FN Dependent upon the services provided A & B
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes Yes A - 25 visits/year Visits paid at Medicare rates, med equipment and supplies paid 90% of Medicare rates A & B
Hospice Care
Yes Prospective rates based on Medicare methodology A & B
Personal Care Services
Yes Plan of care and after 60 hours/month 220 hours/month, nursing assessment every 6 months Monthly rate based on hours of care A & B
Private Duty Nursing Services
No
Program of All-Inclusive Care for the Elderly
No
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
No
Inpatient Psychiatric Services, under age 21
Yes Yes Cost based payment A & B
Intermediate Care Facility Services for the Mentally Retarded
Yes 14 hosp leave days/hospitalization, 21 therapeutic leave days/year Private facilities paid prospective cost based per diem with limits, cost based payment for public facilities A & B
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes Yes 12 hosp leave days/year, 6 therapeutic leave days/year Prospective per diem based on cost assuming 90% occupancy, payment for leave days dependent on occupancy rate A & B
Religious Non-Medical Health Care Institution and Practitioner Services
No


Notes: None
 
 
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