West Virginia Medicaid Benefits

There are no copays for behavioral health and emergency care services. Your Medicaid benefits include:

• Primary care provider (PCP) visits
• Immunizations and wellness visits
• EPSDT (Early and Periodic Screening, Diagnosis and Treatment) 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 health care (mental and substance abuse services)
• Home health care services
• Disease management for asthma, diabetes and more

Some members will pay low copays for some care. See your member handbook for a full list of benefits. 

Registered nurses are available anytime, day or night. They can:

• Advise you on where to go when you need care.
• Help you with any health questions you have.

Call the 24-hour nurse help line 24 hours a day, seven days a week 1-888-850-1108 (TTY 711)

SKYGEN USA Dental provides your dental benefits.

Members under 21 years

• Diagnostic, preventive, restorative, and surgical benefits
• Routine dental care
• Oral exams
• Cleanings
• X-rays
• Orthodontic services
• Fluoride Varnish Program

Members age 21 and older

Preventive dental care — receive up to $2,000 per member per two (2) year period of covered services

• Cleanings
• X-rays
• Fillings
• Crowns

Certain adult preventive services require preapproval.

Emergency dental care

• Treatment of jaw fractures
• Biopsy
• Removing tumors
• Emergency extractions
• Medically necessary emergency procedures from a dentist or oral surgeon

For questions about dental benefits and help finding a dentist in your health plan network, call SKYGEN USA Dental at 877-408-0917 (TTY 800-508-6975) or visit skygenusa.com.

Vision benefits are provided by Superior Vision. Vision services include:

Members under 21 years of age

• Preventive screenings
• Eye exam once a year
• Glasses (frames and lenses) once a year
• Repairs to glasses
• Contact lenses (if medically necessary)
• Medically Necessary Eye surgery (not cosmetic)

Members 21 years of age and older

• 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 1-844-526-0198 (TTY 1-800-523-2847).

UniCare Health Plan of West Virginia, Inc. provides inpatient and outpatient services to members. These benefits include behavioral health services, substance use disorder (SUD) services, case management, rehabilitation and clinic services, and psychiatric residential treatment services.

You do not need a referral for behavioral health services. Some services may require a prior authorization or have limitations. Your primary care provider (PCP) is a good first resource. The Customer Care Center can also help you get these services from behavioral health providers. You can call the Customer Care Center toll free at 800-782-0095 (TTY 711).

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

If you’re feeling suicidal, you need to seek help right away from an emergency room or outreach group, like the National Suicide & Crisis Lifeline at 988. The 988 Suicide & Crisis Lifeline is available 24/7/365.

Your pharmacy benefits are covered under the state Medicaid program and managed by Gainwell Technologies. If you have questions about your benefits, call the Gainwell Technologies Help Desk at 1-888-483-0797.

You can get no-cost rides to your medical appointments. You or your provider should call to schedule your ride at least five business days before your appointment.

To schedule a ride

Call ModivCare at 1-844-549-8353 (TTY 1-866-288-3133).

• WW® (formerly Weight Watchers) meeting for eligible members ages 18 and older
• Active&Fit — eligible members ages 18 and older can receive one gym membership to participating gyms such as Anytime Fitness and YMCAs; and home fitness kits option.
• Youth club memberships to participating clubs like Boys & Girls Clubs for ages 6-18 (not summer camps)
• Oral Care Essentials box with items like an electric toothbrush, toothpaste, and floss for members ages 5 and older who complete a yearly dental visit
• No-cost laptop to help with educational pursuits for graduating high school for students with a GPA of 3.5 or higher or students that have completed the GED/TASC
• Up to $75 in lifestyle aids from a catalog of healthy lifestyle products for members with diabetes, hypertension, or obesity
• Personal hygiene products voucher for members ages 5 and up to purchase up to $50 worth of hygiene products for completing yearly wellness exam
• Feminine care collection for females 10-18; up to $75 worth of feminine care products
• A $100 gas card for members ($25 every 3 months per household) to help members and their families with transportation needs; limit 1 per household
• Summer Camp Sponsorship to Camp KnoKoma for eligible members
• Online Well-Being program — online platform promoting behavioral health and wellness through instruction, games, goal setting, and monitoring for eligible members ages 13 and older
• SUD Recovery Support Program that provides daily motivations/check ins, peer support through discussion groups and peer-to-peer messages, and more for eligible members
• Community Resource Link to locate available local community-based programs, benefits, and services
• Help line and coaching to quit smoking
• NAMI membership for members hospitalized for emotional and mental health condition (membership per household)
• Employment support package for eligible members 18 and up who are enrolled in employment support program
• Filtered water pitchers for eligible member households in target counties and/or receive lead screening ages 0-2

Pregnant members can get:

• Pregnancy and childbirth classes to help you have a healthy pregnancy
• Preventive Dental Care which includes coverage for 2 dental visits per pregnancy
• Baby Essentials $170 gift card for members completing 6 prenatal visits to use toward the purchase of baby items such as:
  • Bottles and nursing supplies
  • Formula and baby food
  • Diapers, wipes, and creams
  • Bathtubs
  • Strollers
  • Car seat
  • Portable crib

You can redeem some benefits online through your secure account. View the extra benefits you’re eligible for on the Benefit Reward Hub or call the Customer Care Center at 800-782-0095 (TTY 711) Monday through Friday, 8 a.m. to 6 p.m. Eastern time.

Limitations and restrictions apply. Benefits may change.

Log in to get started today.

Visit the Benefit Reward Hub

Whether you’re thinking about having a baby, pregnant, already a new mom, or you’re not planning to have a baby, we can help you take steps to stay healthy at every stage.

Learn more

Healthy Rewards is a no-cost, optional program for eligible members enrolled in our health plan. The program encourages you to get the care you need to create a healthy lifestyle.

You can redeem these Healthy Rewards through the Benefit Reward Hub:

• $10 for completing a new member health screener
• $25 for childhood wellness visits for members ages 3-6
• $50 for completing HPV vaccinations series prior to member’s 13th birthday
• $25 for adolescent wellness visits for members ages 12-21
• $50 for breast cancer screenings
• $50 for cervical cancer screenings
• $25 for childhood dental visits 
• Up to $80 for following up with your doctor after being hospitalized for a behavioral health condition
• Up to $40 for ADHD medication management
• $50 for a diabetic retinal eye exam
• $50 for a diabetic A1c and nephropathy screening
• $5 for completing a What do you know about diabetes? quiz

Requesting benefits

Log in to the Benefit Reward Hub to redeem your Healthy Rewards. You can also call the Healthy Rewards Customer Service Line at 888-990-8681 (TTY 711) Monday through Friday from 9 a.m. to 8  p.m. Eastern time.

Redeem Healthy Rewards

You can redeem these Taking Care of Baby and Me® Healthy Rewards through the Benefit Reward Hub:

• $25 for prenatal visit in the first trimester or within 42 days of enrollment into UniCare
• $25 for attending at least six prenatal visits
• $25 for attending postpartum visit 7 to 84 days after delivery
• $25 for well-baby visit within the first 3-5 days of life
• $25 for attending at least six well-child checkups by 15 months of age

Requesting benefits

Log in to the Benefit Reward Hub to redeem your Healthy Rewards. You can also call the Healthy Rewards Customer Service Line at 888-990-8681 (TTY 711) Monday through Friday from 9 a.m. to 8 p.m. Eastern time.

Redeem Healthy Rewards

Referrals

A referral is when your primary care provider (PCP) sends you to some other provider for care. You’ll need to see your PCP for a referral before you see a specialist.

Self-referral

Some types of services are known as self-referral services. That means you can get these services without a referral from your PCP. You don’t need your PCP’s OK for a self-referral if the provider works with us.

• Family planning
• OB/GYN care from providers who work with UniCare
• Pregnancy care
• Emergency care
• Vision care
• Dental care
• Behavioral health care

We’ll also pay for related lab work and most medicines you get at the same place as the self-referral service.

Preapprovals (also called prior authorization)

For some services, your provider will need to get approval, or an OK, from us before you get them. Your PCP will work with us to get preapproval.

You do not need an approval from your PCP for these types of care:

• Family planning
• OB/GYN services from plan providers
• Emergency care
• Vision care
• Behavioral health services

Getting a second opinion

You might have questions about a diagnosis or the care your primary care provider (PCP) says you need. You may want to get a second opinion from another provider. You should speak to your PCP if you want a second opinion. You or your PCP may also ask us for help. You must get services from a provider in our plan. If there is no provider in our plan that fits the care you need, we’ll let you get a second opinion from a provider outside our plan. There is no cost to you for a second opinion.

For information about second opinions or services that need preapproval, please see your member handbook.

• View your member handbook

Some members will have a small copay, or fee, for some services.

There are no copays for:

• Family planning services
• Emergency services
• Behavioral health services
• Members under age 21
• Pregnant women (including up to 60 days after pregnancy)
• American Indians and Alaska Natives
• Members getting hospice care
• 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 administered by a pharmacist

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

You have to pay the copays listed above until you and all family members in your household enrolled in the plan 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.

You will have no copays for the rest of the quarter once your household meets its copay maximum. You also may self-attest (report to us) that you have met the copay maximum. Call our Customer Care Center when you meet your copay maximum. 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 1-800-782-0095 (TTY 711).

We put tools and technologies in your hands to make it easier to access care and services. Your Care Plan is a tool for UniCare Case Management members to help you:

• Stay connected with your care coordinator
• Get your care coordinator’s phone number and email address
• Send secure messages about diagnoses, goals, medicines, services and more
• View your goals and objectives
• Check due dates and statuses of goals and objectives