Benefits and Coverage

The following chart includes a list of all your benefits plus some helpful details about certain benefits. If you have questions about your Medicaid or WV CHIP benefits through Highmark Health Options, look in the latest Member Handbook or call Member Services at 1-833-957-0020 (TTY: 711), Monday–Friday, 8 a.m.–5 p.m.

Extra Benefits from Highmark Health Options

Benefits for expecting and new moms
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  • Eligible members can earn up to $175 for attending scheduled exams before and after baby’s birth.
  • Free Pacify account and app for video visits and calls, 24/7. No appointment needed. Experts answer in 5 minutes or less. Ask about breastfeeding, formula feeding, pumping, weaning, adding solid foods, crying and colic, and teething. Plus look up these topics on the app.
  • Free Count the Kicks app for tracking baby’s daily movements in the third trimester of pregnancy.

Read more about maternity care.

Childhood Development Sensory and Stimulation Toys

For eligible members up to age 12 with autism, ADHD, or other similar diagnosis.

Career Pathways

Covers professional development, mentorship, and employment assistance for high school juniors and seniors (age 16–18) and members transitioning out of treatment or incarceration. Includes opportunities that can lead to getting a job and continuing education.

Diabetes Prevention Program

Age 18 and older: For eligible members diagnosed with both prediabetes and high BMI.

Enhanced Dental Care
  • Age 21 and older: Covers an additional $500 for dental care.
  • Expecting moms of any age are eligible for two extra cleanings before and 6 weeks after giving birth.
Filters For Safe Drinking Water

Covers one water faucet filter system plus two extra filters per household per year. Note: One filter lasts about 4 months.

Foodsmart

A 12-week online program provides eligible members with personalized help and access to affordable healthy food options.

Healthy Rewards Program

Provides the chance to earn rewards of $5–$25 for activities like wellness visits and screenings. Rewards are put on a debit card.

Read more about the Healthy Rewards Program.

Healthy Transitions Meal Delivery

Provides free meal delivery to the home for eligible members who had a hospital stay.

Healthy Weight Program

Age 18 and older: Helps eligible members eat healthier, move more, and lose weight.

Hypoallergenic Pillowcases and Mattress Protectors

For eligible members diagnosed with asthma.

Junior Member Advisory Council

Ages 13–17: Earn a $5 gift card by attending quarterly virtual meetings to offer feedback and express concerns about their health and well-being.

Medication Lock Box

Covers one box per eligible member.

Outdoor Activities Program Sponsorship

Ages 5–18: Covers cost for 4-H clubs, health camps, and other supervised activities, including an ATV safety course.

Shoot Your Shot Vaccine Program

Age 18 and older: Covers the cost of one Class X Hunting/Fishing/Trapping license per year upon receiving annual flu shot.

Wider Circle Program

Age 18 and older: Helps members live happier, healthier lives with social groups in their own neighborhood.

Covered Benefits and Services for Mountain Health Trust

Behavioral Health
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  • Behavioral Health Rehabilitation/Psychiatric Residential Treatment Facility (PRTF). Includes services for children under age twenty-one (21) with mental illness and substance abuse. Limits frequency and amount of services.
  • Inpatient. Hospital services for the diagnosis and treatment of behavioral health and substance use disorder (SUD).
  • Inpatient Psychiatric. Includes treatment through an individual plan of care including post-discharge plans for aftercare. Service is expected to improve the condition or prevent regression so the service will no longer be needed.
    • Under age twenty-one (21). Includes services at a psychiatric hospital or psychiatric unit of a hospital. Certification that community outpatient behavioral health services did not meet the member’s treatment needs is required. Pre-admission and continued stay prior authorization is required. Not covered under West Virginia Health Bridge.
    • Age twenty-one (21) to sixty-four (64). Includes services at an Institution for Mental Diseases (IMD).
  • Outpatient. Includes services for individuals with mental illness and substance abuse. Limits frequency and amount of services. Providers must be ACT certified. Children’s residential treatment is not covered.
  • Psychological Services. May be delivered using telehealth. Some evaluation and testing procedures have frequency restrictions.
  • Drug Screening. Includes laboratory service to screen for presence of one (1) or more drugs of use.
  • Substance Use Disorder (SUD) Services. Includes targeted case management and physician-supervised medication and counseling services provided to treat those with a SUD. Opioid treatment program services will be provided through fee-for-service (FFS) Medicaid.
Dental
  • Adults twenty-one (21) and older. Includes diagnostic, preventive, and restorative services. Services also include emergency procedures to treat fractures, pain, or infection. Coverage limited to $1,000 per calendar year per member.
  • Children under age twenty-one (21). Includes emergency, non-emergency, and orthodontic services.
Emergency
  • Post-Stabilization Services. Includes care after an emergency health condition is under control. Care provided in a hospital or other setting.
  • Emergency Transportation. Includes ambulance and air ambulance. Out of state needs prior authorization. To call for emergency transportation, dial 911.
Family Planning
  • Family Planning. Includes all family planning providers and services. No referral needed for out-of-network providers. Prior authorization is not required.
  • Sterilizations. Covers sterilizations for those who are age twenty-one (21) and older and not in an institution or considered mentally incompetent.
  • Hysterectomies, pregnancy terminations, and infertility treatments. Not covered.
Home Health Care

Includes services given at member’s residence. This does not include a hospital nursing facility, ICF/IDD, or state institutions. Some suppliers have service limits.

Hospice

Includes nursing care, physician services, medical social services, short-term care, durable medical equipment, drugs, biologicals, home health aide, and homemaker. Requires physician certification. For adults ages twenty-one (21) and older, rights are waived to other treatment services related to the terminal illness.

Hospital
  • Inpatient. Includes all inpatient services (including bariatric and corneal transplants). Transplant services must be in a center approved by Medicare and Medicaid. Adults in institutions for mental diseases and some behavioral health inpatient stays are not included.
  • Outpatient. Includes preventive, diagnostic, therapeutic, all emergency services, and rehabilitative medical services.
Maternity
  • Maternity Care. Includes prenatal, inpatient hospital stays during delivery, and post-partum care. Home birth is not covered.
  • Right From The Start. Includes prenatal care and care coordination. No prior authorization needed.
Medical
  • Primary Care Office Visits and Referrals to Specialists.
  • Physician Services. Certain services may need prior authorization or have service limits. May be delivered through telehealth.
  • Laboratory and X-Ray Services. Includes lab services related to substance use disorder (SUD) treatment. A physician must order the services, and certain procedures have service limits.
  • Clinics. Includes general clinics, birthing centers, and health department clinics. Vaccinations are included for children.
Nursing
  • Nurse Practitioner Services. Some procedures have service limits.
  • Private Duty Nursing. Includes twenty-four (24)-hour nursing care (not covered for adults ages twenty-one (21) years and over). Prior authorization may be needed.
Other
  • Federally Qualified Health Centers. Includes physician, physician assistant, nurse practitioner, and nurse midwife services.
  • Prosthetics. Customized special equipment is considered. Certain procedures have services limits or need prior authorization.
  • Durable Medical Equipment. Covered in nursing facilities and intermediate care facilities for individuals with intellectual/developmental disabilities (ICFs/IDD). Customized special equipment is considered. Certain procedures have services limits or need prior authorization.
  • Ambulatory Surgical Care. Includes services and equipment for surgical procedures. Physician services; lab and x-ray; prosthetic devices; ambulance; leg, arm, back, and neck braces; artificial limbs; and DME are not covered.
  • Organ and Tissue Transplants. Corneal transplants only.
  • Gender Affirmation for Gender Dysphoria. Procedure that aligns an individual’s biological sex with their gender identity. Adults must be twenty-one (21) years or older prior to being considered for the procedure. Prior authorization is required.
Preventive Care and Disease Management
  • Early and Periodic Screening, Diagnosis, and Treatment (EPSDT). Includes health care services for any medical or psychological condition discovered during screening (for children under age twenty-one (21) only).
  • Tobacco Cessation. Includes therapy and counseling and Quitline services. Guidance and risk-reduction counseling covered for children.
  • Sexually Transmitted Disease Services. Includes screening for a sexually transmitted disease from your PCP or a specialist in our network.
Rehabilitation
  • Physical Therapy. Thirty (30) visits per year for habilitative and rehabilitative services (combined for physical and occupational therapy).
  • Occupational Therapy. Thirty (30) visits per year for habilitative and rehabilitative services (combined for physical and occupational therapy).
  • Speech Therapy. Habilitative and rehabilitative services including hearing aid evaluations, hearing aids and supplies, batteries, and repairs (for children under age twenty-one (21). Some procedures have service limits or need prior approval.
  • Chiropractor Services. Includes radiological exams and corrections to subluxation. Certain procedures have service limits.
  • Pulmonary Rehabilitation. Includes procedures to increase strength of respiratory muscle and functions.
  • Cardiac Rehabilitation. Includes supervised exercise sessions with electrocardiograph monitoring.
  • Inpatient Rehabilitation. Includes inpatient rehabilitation services and general medical outpatient services that meet the certification requirements.
Specialty
  • Podiatry. Includes treatment of acute conditions for children and adults. Includes some surgeries, treatment of fractures and other injuries, and orthotics. Routine foot care is not covered.
  • Handicapped and Children with Special Health Care Needs Services. Includes coordinated services and limited medical services, equipment and supplies.
Vision

Includes eye exams, treatment, lenses, frames, and repairs for children under twenty-one (21) years of age. Includes medical treatment, one pair of glasses after cataract surgery, and contact lenses (for certain diagnosis) for adults twenty-one (21) years of age and older. Does not cover prescription sunglasses or designer frames.

Covered Benefits and Services for WV CHIP

Abortion
Open

Includes drugs or devices to prevent implantation of fertilized ovum and medical procedures for termination of ectopic pregnancy. Physician certification required. Compliance with all applicable Federal and State laws is required for this benefit.

Early Intervention Services for Children Three (3) and Under

Includes services and supports provided through the West Virginia Birth to Three program for children under age three (3) who have a delay in their development, or may be at risk of having a delay, and for their families.

ICF/IDD Intermediate Care Facility

Includes physician and nursing services, dental, vision, hearing, lab, dietary, recreational, social services, psychological, habilitation, and active treatment for intellectual/developmental disabilities. Requires physician or psychiatrist certification.

Nonemergency Transportation

Includes multi-passenger van services and common carriers (example: public railways, buses, cabs, airlines, ambulance as appropriate and private vehicle transportation). Prior authorization is required. To get transportation, call ModivCare at 1-844-889-1941 (TTY: 1-866-288-3133).

Nursing Facility Services

Includes nursing, social services, and therapy.

Organ Transplant Services

Generally safe, effective, medically necessary transplants covered when no alternative is available. Cannot be used for investigational/ research nature or for end-stage diseases. Must be used to manage disease.

Personal Care Services

Includes personal hygiene, dressing, feeding, nutrition, environmental support, and health-related functions. Room and board services require physician certification. May not exceed sixty (60) hours per month without prior authorization.

Personal Care for Aged/Disabled

Includes assistance with daily living in a community living arrangement, grooming, hygiene, nutrition, physical assistance, and environmental for individuals in the Aged and Disabled Waiver. Limited on per unit per month basis. Requires physician order and nursing plan of care.

Prescription Drugs

Includes dispensed on an ambulatory basis by a pharmacy, family planning supplies, diabetic supplies, vitamins for children, and prenatal vitamins. Hemophilia blood factor, Hepatitis-C, weight gain, cosmetic, hair growth, fertility, less than effective and experimental drugs are not covered. Drugs dispensed by a physician at no cost are not covered.

School-Based Services

Service limitations are listed in the FFS Medicaid policy manual. Services not covered by WVCHIP.

Substance Abuse Services

Physician-supervised opioid agonist medication and counseling services provided to those with severe opioid use disorder.

Tubal Ligation

Family planning service for individuals of childbearing age to permanently prevent pregnancy. Service requires informed consent and medical necessity.

Your Covered Benefits and Services

You can get many services through Highmark Health Options. For most benefits, you will need to go through your doctor or primary care physician (PCP). There are some services that do not require a referral from your PCP. This means that you do not need approval from your PCP. Look in the Provider Directory for the list of providers who offer these services. You can schedule the appointment yourself.

Your covered services must be medically necessary. You should get these services from providers in the Highmark Health Options network. Your PCP should provide covered services or refer you to another provider to do so. These include medical, behavioral, dental, and vision services. You can get the services listed above by using your Highmark Health Options member ID card.

Not Covered Benefits and Services 

Some services are not available through Highmark Health Options, Medicaid, or CHIP. If you choose to get these services, you may have to pay the entire cost of the service. Highmark Health Options is not responsible for paying for these services and others:

  • All services not considered medically necessary. 
  • Services from non-enrolled or non-participating providers. 
  • Services that require a prior authorization but did not get a prior authorization. 
  • Sterilization of a mentally incompetent or institutionalized individual. 
  • Except in an emergency, inpatient hospital tests that are not ordered by the attending physician or other licensed practitioner, acting within the scope of practice, who is responsible for the diagnosis or treatment of a particular patient’s condition. 
  • Organ transplants, except in some instances. 
  • Treatment for infertility and the reversal of sterilization. 
  • All cosmetic services, except in the case of accidents or birth defects. 
  • Christian science nurses and sanitariums.

This is not a complete list of the services that are not covered by Medicaid. If you have a question about whether a service is covered, call Member Services at 1-833-957-0020 (TTY: 711).