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West Virginia Health Insurance

West Virginia Medical Insurance Overview

There are many options for health insurance coverage within the state of West Virginia.  Many residents working in this state obtain group health coverage through the workplace, but for others, this option isn’t always available.  Depending on your level of income and the situation, you may be able to get coverage through a state-funded program that is fairly cheap or free.  Despite the many options that are currently available for insurance in West Virginia, there are many residents who don’t have insurance coverage at all.  The Affordable Care Act has made it easier for uninsured residents to compare their options and seek insurance policies, but there are vast numbers of people living in this state who have yet to do so.

The summary provided looks at all of the state’s health care issues, the benefits exchange and coverage options that are available to residents in the state of West Virginia.

West Virginia’s Health Care Issues
The United Health Foundation ranks West Virginia in the 47th spot when it comes to the overall health of the residents living there.  There are several strengths and challenges for the state to overcome as listed below:

Low incidence of infectious disease
Low prevalence of excessive drinking
High per capita public health funding

High prevalence of smoking
High prevalence of diabetes
Low immunization coverage among children

It is hoped that Obamacare will offer higher percentages of insured residents so that they may diminish the challenges faced by the state’s residents.

Understanding West Virginia’s Uninsured Population
According to a report from the Kaiser Family Foundation, the percentage of people who are uninsured in West Virginia is sitting at 6 percent.  This is a significant drop from 14 percent in the year 2011.

Statistics show the following information regarding the non-elderly uninsured population of the state of West Virginia:

  • 10% of uninsured people earn less than 100% of the Federal Poverty Level (FPL)
  • 11% earn between 100-199% of the FPL
  • 8% earn between 200-399% of the FPL
  • Of those earning over 400% of the FPL, there are 4 percent without insurance coverage

In West Virginia, 43% of people are covered under group insurance plans, while individual plans cover 4% of the population, 37% are covered using public means and 6% have no insurance whatsoever.

Group Health Plans
Group plans are insurance policies that are available through the workplace and can extend to cover the employee’s spouse and dependents.  In West Virginia, companies are not required to offer insurance policies to their workers.  In the event that an employer does offer health insurance, it must be available company-wide to all who qualify.

Benefits are usually offered to only full-time employees in the state of West Virginia.  Employers are given the opportunity to negotiate how much of the premiums they will cover, but it is sometimes dictated by the insurance company.

Under a group policy, you cannot be turned down for coverage because you have a pre-existing condition.  Despite that, you may be subject to waiting out a six month waiting period unless you are under the age of 19.  Insurance companies who offer coverage to small companies with less than 50 workers are not able to consider pregnancy as a pre-existing medical condition.

Under the law in this state, all health insurance plans must offer coverage for primary health and nursing care services.  For those plans that cover lab tests and x-rays, pap smears and mammograms must also be offered along with cancer screenings and rehabilitation services.

West Virginia Insurance Continuation and COBRA
In the state of West Virginia, if you have lost insurance coverage under a group plan because of an involuntary layoff, you can receive continuation coverage that lasts for 18 months.  It also must contain the same provisions and costs that the original policy offered.

COBRA coverage is continuation coverage offered on a federal level and offers more extensive benefits for those who qualify.  COBRA insurance coverage is applicable to companies that employ more than 20 workers and the continuation law in West Virginia only covers two or more employees.  There is also a second chance election period that is part of the ARRA (American Recovery and Reinvestment Act of 2009).

Individual Health Plans
This plan type is available to people who cannot obtain insurance coverage through their job, but wish to have coverage.  An individual policy may be bought from an agent or through the insurance provider themselves.  In order to apply for coverage, you must complete a Standard Health Statement which is a detailed application for insurance benefits.  Insurers can use this statement to determine if coverage can be granted or denied based on a pre-existing medical condition.  When filling out this statement, be sure to remain as honest and as accurate as possible.

Premiums charged for individual plans can differ based on the options wanted, the age of the applicant, the size of the family getting coverage and the location within the state that the applicant residents.  Claims history or health cannot determine rates charged, however they can be increased as the applicant moves to different age brackets.

With individual insurance policies, the state of West Virginia mandates that primary nursing care services, cancer screenings, x-rays and lab testing be offered under the insurance contract.
West Virginia Health Benefit Exchange
In the state of West Virginia, the health benefits marketplace is located at and offers plan options for residents to compare and purchase health insurance coverage.

The Affordable Care Act mandated that every state have an active health benefits marketplace up and running by October 2013.  Using the exchange, residents can learn the open enrollment period for applications, get resources for the healthcare reform in the state and subscribe to receive information related to the Affordable Care Act.

The state now operates a Partnership Marketplace that has plan management responsibilities.

West Virginia State Insurance Programs
If you reside in West Virginia and your income is on the low side, you can apply for health insurance coverage through one of the many state-funded programs.  They are all listed below in detail.

West Virginia Medicaid
The Medicaid program provides participants with a medical card that can be used for obtaining medical care in hospitals, clinics and nursing homes.  This program is offered to people who may not have previously been able to afford treatment due to the rising cost of healthcare.  In order to qualify for Medicaid, you must be a resident of West Virginia, in need of health insurance coverage, and earn a low income.  In addition, services under this program may be available to individuals that are pregnant, disabled, or parents of a minor child.  Eligibility is determined using your income and assets with the exception of pregnant women.

West Virginia Medicaid for Long Term Care
This is a long-term care Medicaid program and there are four plans that are available to choose from.  The SSI-Related Medicaid for Nursing Home Care program offers payment for nursing home care for disabled, blind or aging individuals.  Income limits for this type of coverage are 300% of the FPL.  Home and Community Based Care is a program that works to keep elderly people in their homes who require nursing home levels of care.  The Intermediate Care Facility is a program that covers the costs of institutional care of people that have received a diagnosis of mental retardation.  The Mental Retardation/Developmental Disability Waiver is a program that offers payment for in-home medical services for people with developmental disabilities or retardation.  Medical services under this program can be provided in a nursing home, facility or hospital setting.

West Virginia Children’s Health Insurance Program (WV CHIP)
The CHIP program offers medical insurance to families with children.  Services covered under this program include doctor’s visits, checkups, hospital stays, dental and vision services, immunization coverage, prescription medications, emergency services, mental health care and special needs case management services.

In order to be eligible, the child must be a resident of West Virginia and a U.S. citizen, be under the age of 19, lost family insurance coverage in the previous three months, be ineligible for Medicaid coverage, ineligible for state employee health insurance and be a part of a family whose size and income meet the required guidelines.

West Virginia WISEWOMAN
The WISEWOMAN program offers stroke screenings and factors related to heart disease.  It targets related risk factors that include hypertension, blood pressure abnormalities, tobacco use, high BMI and diabetes.  It also offers education and counseling services to reduce the risk factors for heart disease, stroke and other chronic diseases.  It promotes good nutrition, physical activity and smoking cessation.
Medicare Premium Assistance Program
This program is aimed at the disabled or elderly residents of West Virginia that are currently receiving Medicare assistance.  Under this program, there are three options available:

  • Qualified Medicare Beneficiary: Offers help in paying Medicare Part A and Part B premiums along with co-payments and deductibles.  Income limit is set to 100% of the FPL.
  • Specified Low-Income Medicare Beneficiary: Offers payment for the Medicare Part B premium and the income requirement is 120% of the FPL.
  • Qualified Individual: This program pays the Medicare Part B premium with an income limit of 135% of the FPL.

West Virginia Right from the Start
Under this program, pregnant women can meet with a care coordinator to learn how to maintain a healthy pregnancy.  The care coordinator can offer access to resources within the community to help with your needs.  In order to qualify for this program, you must be a pregnant woman living in the state of West Virginia and have an active Medicaid program.

HIV/AIDS Program
Under this program, at risk people can receive informational services on risk reduction and health education to prevent HIV/AIDS.  Participants can receive HIV testing and counseling services along with youth peer education and community planning groups.

West Virginia Breast and Cervical Cancer Screening Program
This program offers services that screen women for breast and cervical cancers.  For women who receive abnormal screenings, there is also diagnostic testing available.  Through education and outreach, these services offer a comprehensive program that aims to lower the percentage of women suffering from cancer in West Virginia.

Vaccines for Children “VFC”
This program offers vaccinations to children of whose parents cannot afford to pay for them.  This is done free of charge and covers children in the state of West Virginia who are not currently insured.  Medicaid participants can also receive immunizations free and coverage is available to children whose insurance policy does not offer vaccinations.

West Virginia Family Planning Program
Low cost and free birth control choices are available to people who are eligible for this program.  These free birth control methods include condoms, birth control pills and abstinence information.  There are also a variety of medical exams you can obtain under this program including pap tests, breast exams, pelvic exams, testicular exams along with screenings and treatments for STDs.

This is West Virginia’s high risk insurance pool program and offers coverage to those suffering from a pre-existing medical condition or a condition that is considered severe or chronic.  Plan options are made available to residents who have had trouble obtaining insurance or have been denied coverage because of a pre-existing, chronic or severe condition.  It can also cover those who are eligible through the IRS Health Coverage Tax Credit Program’s Federal Portability Act.

There are four plans available under this program: A, B, C and D.  Each of these plans charge different out of pocket maximums, deductible amounts and monthly premiums.  Family or single coverage is offered through Plans A, B and C, but D offers individual coverage.  The age of the applicant is taken into account along with the person’s gender and county of residence.  Medical providers are reimbursed using a fee schedule that is determined by the Public Employees Insurance Agency.

West Virginia Health Insurance Portability and Accountability Act (HIPAA)
Under the HIPAA legislation in West Virginia, group health plans cannot impose an exclusion period for pre-existing conditions if the employee has had creditable coverage for 12 months and has had a gap of under 63 days in coverage.  HIPAA only allows for pre-existing exclusion periods for people who have been treated for these conditions in the six months prior to enrollment in the group plan.  Under the terms of pre-existing conditions, pregnancy cannot be considered, nor can your genetic information.