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Medicaid, SCHIP, & Federal Authority

  • The Deficit Reduction Act of 2005 (DRA) - In May 2006, West Virginia received approval from the Centers for Medicare and Medicaid Services (CMS) to move forward on plans to redesign its Medicaid program. Taking advantage of the flexibility outlined in the DRA, West Virginia utilized the state plan amendment process. A four-year, phased in implementation began in July 2006. The West Virginia reform streamlines eligibility and moves healthy children and parents into one of two plans:

    • Basic Plan: The plan covers all mandatory and some optional services, but benefits are more limited than the state’s previous Medicaid benefits package. Children continue to receive services under the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit. Enrollees can access additional benefits covered by the Enhanced Plan by signing a member agreement.  
    • Enhanced Plan: For individuals who have signed a member agreement, this plan covers all the services included in the Basic Plan plus mental health services, diabetes care, and prescription drugs above the four-drug limit in the Basic Plan. The Enhanced Plan is comparable to the state’s previous Medicaid benefits package.

    The cornerstone of West Virginia’s plan is the member agreement and the Healthy Rewards pilot program. Enrollees who sign a member agreement, a ‘personal responsibility contract,’ are enrolled in the Enhanced Plan and receive a fixed amount of credits per quarter in a Healthy Rewards account. The credits can be used to cover medical and pharmaceutical co-pays and bonus credits are added for meeting health goals. Individuals who do not meet their responsibilities are moved to the more limited Basic Plan.

    State Children’s Health Insurance (SCHIP) Expansion – In December 2006, West Virginia received approval from CMS to increase SCHIP eligibility from 200 percent of the FPL to 220 percent of the FPL. Children in the new eligibility level will have different cost-sharing requirements and benefits from children with family incomes at or below 200 percent of the FPL. For example, individuals in the expanded eligibility category will be required to pay monthly premiums and will not receive vision services.

High-Risk Pools

  • The West Virginia high-risk pool, known as AccessWV, became operational in 2005. The program is financed through premiums and an assessment on hospitals. The premium cap is not less than 125 percent of the standard individual risk rates for comparable coverage, but shall not exceed 150 percent.   At the end of June 2006, over 200 individuals were receiving coverage through the pool.

State Specific Strategies

  • West Virginia Small Business Plan - The West Virginia Small Business Plan allows small businesses access to the buying power of the Public Employees Insurance Agency (PEIA). Through a private-public partnership between the West Virginia Public Employees Insurance Agency (PEIA) and insurance companies that choose to offer the plan, the West Virginia Small Business Plan allows participating carriers to access PEIA’s reimbursement rates, enabling the new small business coverage cost to be reduced significantly. PEIA is the largest self-insured plan in the state, providing insurance to public employees in state agencies, state universities, and colleges, as well as county boards of education.  The Small Business Plan has similar goals to group purchasing arrangements because it builds on the buying power of a large group.  Program enrollment began in January 2005 and, as of the Fall of 2006, more than 1,200 were enrolled, representing 300 businesses.   

    To learn more about this initiative, read SCI's Profile in Coverage