WEST VIRGINIA'S STATE PLAN AMENDMENT

On May 3^rd, the Centers for Medicare and Medicaid Services approved West Virginia’s request to modify its Medicaid benefit package for certain enrollees. The West Virginia State Plan Amendment—allowed for under the Deficit Reduction Act of 2005 and not as comprehensive as a waiver—will provide enrollees with a basic plan, which includes all federal and state mandatory services, or an enhanced plan that offers additional health care services to members who elect to sign, and comply with, a member agreement.

The agreement outlines member rights and responsibilities. Members who chose to sign the agreement must agree to several conditions, including:

Going to a medical home for check-ups;

Arriving on time for check-up appointments; and,

Using the hospital emergency room for emergencies only.

In exchange for signing the member agreement, these individuals will receive a richer package of benefits. For example, under the enhanced benefit plan, adults will have coverage for chiropractic services, cardiac rehabilitation, stop-smoking programs, diabetes care, emergency dental services and limited chemical dependency and mental health services—all services not covered under the basic plan.

The HMO or medical home will monitor the extent to which members are complying with their responsibilities. Remaining in the enhanced category requires compliance with the following four responsibilities:

Screenings as directed by the health care provider

Adhering to health improvement programs as directed by their provider

Keeping appointments

Medication compliance

If the member does not comply, they will be moved to the basic benefit plan. (Members will have an opportunity to appeal this decision.) After one year in the basic plan, enrollees will have an opportunity to sign the member agreement and re-enroll in the Enhanced Plan. In other words, there will be movement between the benefit packages, and this will be determined by member compliance as well as a member’s decision to sign the agreement.

The plan will be phased in gradually throughout the state, and eventually operate statewide for eligible members—who include healthy children and healthy adults on Medicaid. In addition to the specified services, enrollees will receive wrap-around or additional benefits for people under age 19 to guarantee that early and period screening, diagnostic and treatment services are provided when medically necessary. The State Plan Amendment will be implemented on July 1, 2006.
Link to 1115 Waivers and Amendments page