West Virginia Medicaid benefits

As a Wellpoint member in West Virginia, you get many benefits with little to no costs or copays, plus extras to help you live well.

Medical care is just the beginning

With Wellpoint, you’ll also have access to a wide range of services including dental care and our Healthy Rewards program.

There are no copays for behavioral health and emergency care services. Some of your other services may require a small copay. Your Medicaid benefits include:

Primary care provider (PCP) visits
Immunizations (shots)
Wellness visits
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services for members under 21.
Specialist visits
Urgent and emergency care
Hospital care
Lab and X-ray services
Pregnancy services
Family planning
Chiropractic services
Physical and occupational therapy
Speech and hearing services
Behavioral healthcare (mental and substance use disorder (SUD) services)
Home healthcare services
Disease management for asthma, diabetes, and other conditions

Find care

Dental benefits are provided through SKYGEN USA Dental. Some SKYGEN USA Dental benefits for Wellpoint members include:

Diagnostic, preventive, restorative, and surgical dental care.
Routine dental exams and care
Oral exams
Dental cleanings
X-rays
Orthodontic services
The Fluoride Varnish Program
Treatment of jaw fractures
Biopsy
Removal of tumors
Emergency extractions
Medically necessary emergency procedures from a dentist or oral surgeon.

Dental benefits for members ages 21 and over are limited to $2000 over a two-year period.

For questions about your dental benefits, call SKYGEN USA Dental at 877-408-0917 (TTY 800-508-6975), or visit skygenusa.com .

Find a dentist

Vision benefits are provided by Superior Vision to Wellpoint WV Medicaid members.

Vision care for members 20 or younger can receive:

Preventive screenings.
An eye exam once a year.
Glasses (frames and lenses) once a year.
Repairs to glasses.
Contact lenses if they’re medically needed.
Medically necessary eye surgery (not cosmetic).

Members 21 and older can receive vision care such as:

Medically necessary services needed to diagnose and treat eye conditions.
Dilated eye exam for diabetic members.
One pair of eyeglasses after cataract surgery.
Some contact lenses.

To learn more about your vision benefits, call Superior Vision at 844-526-0198 (TTY 1-800-523-2847).

Find an eye care specialist

As a Wellpoint member, you have access to many inpatient and outpatient services. These benefits include:

Behavioral health services
Substance use disorder (SUD) services
Case management
Rehabilitation and clinic services
Psychiatric residential treatment services (for members 21 and under)

You do not need a referral for most behavioral health services. Some services may require a prior authorization or have limits. Your primary care provider (PCP) is a good first resource to ask about these services.

The Customer Care Center can also connect you with behavioral health providers. You can call the Customer Care Center at 800-782-0095 (TTY 711), or chat with a live representative on the Sydney^SM Health app.

If you’re having a behavioral health crisis, call the 988 Suicide and Crisis Lifeline for help. If the situation is life‐threatening, always call 911.

A prior authorization is when your primary care provider (PCP) needs to ask us to approve a service, or get an ‘OK’, from us before you have it. Your PCP will work with us to get the prior authorizations you need. If you need tests or a specialist, your PCP will help you get this care. This is called a referral. If you’re unsure what you need approvals or referrals for, check the Referrals and prior authorizations page for more information.

Healthy Rewards is a program that pays you for taking control of your health. You can earn rewards for:

Quitting smoking.
Going to prenatal and postpartum visits.
Getting diabetic screenings.
And other healthy activities.

You can redeem your Healthy Rewards on the Benefit Reward Hub, and review how to earn rewards on the Healthy Rewards page. To learn about other extra benefits, visit the Extra Benefits page.

Copay information

You might have a small copay, or fee, for some services.

There are no copays for:

Family planning services.
Emergency services.
Behavioral health services.
Members 20 and younger.
Pregnant members (including up to 60 days after pregnancy).
American Indians and Alaska Natives.
Members getting hospice care, or in nursing homes.
Other members or services not under the State Plan authority.
Members who have met their household maximum limit for copays per calendar quarter.
Members with primary insurance other than Medicaid.
Approved home infusion supplies.
Vaccines given by a pharmacist.

Your potential copays:

The amount you pay depends on the service and your income compared to the Federal Poverty Level (FPL).

Potential cost of services for households	Income up to 50.00% of the FPL	Income between 50.01 to 100.00% of the FPL	Income 100.01% and above the FPL
Inpatient hospital (acute care)	$0	$35	$75
Office visits (physicians and nurse practitioners)	$0	$2	$4
Outpatient surgical services in a physician’s office, ambulatory surgical center, or outpatient hospital (excluding emergency rooms (ER))	$0	$2	$4
Non-emergency use of the ER	$8	$8	$8

Income up to 50.00% of the FPL
Potential cost of services for households
Inpatient hospital (acute care)	$0
Office visits (physicians and nurse practitioners)	$0
Outpatient surgical services in a physician’s office, ambulatory surgical center, or outpatient hospital (excluding emergency rooms (ER))	$0
Non-emergency use of the ER	$8

Income between 50.01 to 100.00% of the FPL
Potential cost of services for households
Inpatient hospital (acute care)	$35
Office visits (physicians and nurse practitioners)	$2
Outpatient surgical services in a physician’s office, ambulatory surgical center, or outpatient hospital (excluding emergency rooms (ER))	$2
Non-emergency use of the ER	$8

Income 100.01% and above the FPL
Potential cost of services for households
Inpatient hospital (acute care)	$75
Office visits (physicians and nurse practitioners)	$4
Outpatient surgical services in a physician’s office, ambulatory surgical center, or outpatient hospital (excluding emergency rooms (ER))	$4
Non-emergency use of the ER	$8

You must pay the copays listed above until you and everyone in your household enrolled in Wellpoint get to the household copay maximum. Your household copay maximum is based on your household income. You’re assigned to a tier based on your household size and income for the quarter.

Tier	Gross quarterly income range	Copay maximum
Tier 1	$0 - 1,966	$8
Tier 2	$1,967 - $3,932	$71
Tier 3	$3,933 and above	$143

Gross quarterly income range
Tier
Tier 1	$0 - 1,966
Tier 2	$1,967 - $3,932
Tier 3	$3,933 and above

Copay maximum
Tier
Tier 1	$8
Tier 2	$71
Tier 3	$143

You will have no copays for the rest of the quarter once your household meets its copay maximum. You may also tell us that you have met the copay maximum. Call our Customer Care Center, or tell a live representative on the Sydney Health app. Keep all your household copay receipts to show you have met the copay maximum.

You will start each quarter with $0 in copays and build toward your copay maximum. For more information on copay amounts, please call the Customer Care Center at 800-782-0095 (TTY 711), or ask about your copay information on the Sydney Health app.