WV Medicaid Eligibility
(Who Qualifies?)

Before we talk benefits, here’s who qualifies:

Adults (19-64):
Income ≤138% of federal poverty level – Individual: $20,783 annual
income – Couple: $28,208
– Family of 4: $42,772

WV expanded Medicaid under the ACA, so childless adults can qualify
(unlike some states).

Children:
Income ≤150% FPL

Pregnant women:
Income ≤185% FPL

Seniors 65+ and people with
disabilities:
Different income/asset rules (usually stricter)

How to apply: dhhr.wv.gov/apply or call
1-877-716-1212

Doctor Visits and Preventive
Care

Primary Care Physician (PCP)
Visits

Covered: ✅ Yes, unlimited visits with no copay

How it works: Choose a primary care doctor from your
plan’s network. They’re your main point of contact for routine care,
referrals to specialists, and chronic disease management.

Finding a PCP: Call your Medicaid plan or search
online: – Aetna: aetnabetterhealth.com/westvirginia – THP:
wvfamily.wvdhhr.org – UniCare: unicarestateplan.com

What’s covered (no copay): – Annual physical exams –
Sick visits – Chronic disease management (diabetes, hypertension,
asthma) – Well-child visits – Immunizations

Specialist Visits

Covered: ✅ Yes, usually requires PCP referral

Common specialists covered: – Cardiologists –
Endocrinologists (diabetes, thyroid) – Dermatologists –
Gastroenterologists – OB/GYNs (no referral needed for routine care) –
Psychiatrists – Orthopedists

Wait times: Vary widely. Urban areas (Charleston,
Morgantown): 2-6 weeks. Rural areas: 6-12 weeks or may need to
travel.

Challenge: Many specialists don’t accept Medicaid
(low reimbursement rates). Your plan’s network might be limited.

Prescription Drug Coverage

Covered: ✅ Yes, but with restrictions

WV Medicaid uses a “formulary”—a list of covered medications. Most
common drugs are covered, but some require prior authorization.

How Prescription Coverage
Works

Copays: $0.50-$3 per prescription (very low)

Where to fill prescriptions: Most pharmacies accept
Medicaid (CVS, Walgreens, Walmart, Kroger, local pharmacies)

Limits: – Generic required when available (unless
doctor documents medical necessity for brand-name) – Some medications
require prior authorization (doctor must submit paperwork explaining why
you need it) – Quantity limits on some drugs

Common Medications Covered

✅ Diabetes: Metformin, insulin, test strips
✅ Blood pressure: Lisinopril, amlodipine,
hydrochlorothiazide
✅ Cholesterol: Atorvastatin (Lipitor generic),
simvastatin
✅ Mental health: Sertraline (Zoloft), fluoxetine
(Prozac), bupropion (Wellbutrin)
✅ Pain: Ibuprofen, naproxen, tramadol (opioids require
prior auth)
✅ Antibiotics: Amoxicillin, azithromycin,
cephalexin

Medications That
Require Prior Authorization

Some drugs need doctor justification before approval: – Expensive
brand-name drugs with generic alternatives – Controlled substances
(opioids, stimulants) – Specialty medications – Weight loss drugs
(rarely approved, only for diabetes)

How long does prior auth take? 3-7 business days
usually. Your pharmacist will tell you if prior auth is needed.

Medications NOT Covered

❌ Over-the-counter drugs (unless prescribed)
❌ Weight loss medications (except for diabetes treatment)
❌ Fertility medications
❌ Cosmetic medications (like Rogaine for hair loss)

Dental Coverage

Covered: ⚠️ Yes, but limited for adults

Children (under 21)

Full dental coverage including: – Routine cleanings
(every 6 months) – Exams – X-rays – Fillings – Extractions – Root canals
– Crowns – Braces (if medically necessary)

Adults (21+)

Limited coverage: – ✅ Emergency dental (pain,
infection, trauma) – ✅ Extractions – ❌ Routine cleanings (not covered)
– ❌ Fillings (not covered) – ❌ Root canals (not covered unless
emergency) – ❌ Crowns, bridges, dentures (not covered)

Pregnant women get expanded dental coverage during
pregnancy and 60 days postpartum.

Where to go: Find Medicaid dentists at
wvdhhr.org/bms/Members/findprovider.asp (limited availability—many
dentists don’t accept adult Medicaid).

Pregnancy and Childbirth

Covered: ✅ Fully covered, no copay

What’s Covered

✅ Prenatal care: All doctor visits, ultrasounds,
lab tests
✅ Delivery: Hospital birth or home birth with
certified midwife
✅ Postpartum care: Follow-up visits for 60 days after
delivery
✅ Breastfeeding support: Lactation consultants, breast
pumps
✅ Family planning: Birth control, IUDs,
sterilization
✅ Prenatal vitamins: Covered prescription

WV Medicaid for pregnant women covers up to 185%
FPL—higher than regular Medicaid. Apply immediately if pregnant and
uninsured.

Coverage extends 12 months postpartum (as of 2024
policy change).

Transportation to
Medical Appointments

Covered: ✅ Yes, free transportation

WV Medicaid Medical Transportation Program provides
free rides to covered medical appointments if you don’t have
transportation.

How it works: 1. Call LogistiCare (WV’s
transportation broker): 1-844-549-8353 2. Request ride at least 3
business days before appointment (2 weeks for wheelchair van) 3. They
send cab, van, or volunteer driver to pick you up

What’s covered: – Rides to doctor, dentist,
pharmacy, hospital – Wheelchair-accessible vans if needed – Mileage
reimbursement if you have a car but can’t afford gas

Real user experience – Linda from Wayne
County:
“I don’t drive and live 30 minutes from my doctor. LogistiCare sends a
van to pick me up. Sometimes they’re late, but it’s free and beats
trying to find a ride from family every month.”

How to Use Your WV
Medicaid Benefits

Step 1: Get Your Medicaid
Card

Once approved, you’ll receive plastic Medicaid card in mail (7-10
days). Card shows: – Your name and Medicaid ID number – Which plan
you’re on (Aetna, THP, or UniCare) – Member services phone number

Step 2: Choose a Primary
Care Doctor

Call your plan and choose a PCP from their network. This is your main
doctor for routine care and referrals.

Step 3: Show Your Card

Bring Medicaid card to all appointments, pharmacy visits, ER trips.
Providers verify coverage electronically.

Step 4: Know When You Need
Referrals

• PCP visits: No referral needed
• OB/GYN: No referral needed
• Emergency care: No referral needed
• Most specialists: Referral from PCP required

Step 5: Use Member Services

Each plan has member services hotline (on back of card). Call if you:
– Need help finding a doctor – Have questions about coverage – Want to
file a complaint – Need transportation

The Bottom Line

WV Medicaid covers comprehensive healthcare: doctor visits, hospital
care, prescriptions, mental health, pregnancy, emergency care, and
medical equipment—all with minimal out-of-pocket costs.

Limitations to know about: – Provider networks can
be limited (especially specialists in rural areas) – Some medications
require prior authorization – Adult dental is emergency-only – Wait
times for specialists can be long

But if you qualify, WV Medicaid provides real healthcare coverage.
Use it.

Don’t avoid care because you’re worried about costs.
If you’re on Medicaid, you’re covered. The whole point is to get you
healthcare without financial barriers.

Related Guides: – WV Mental Health Resources – Finding Affordable Healthcare in
WV