Medicaid, SCHIP, and Federal Authority²

Medicaid Reform

In May 2006, West Virginia received CMS approval 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.

High-Risk Pool  

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.

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: West Virginia Small Business Plan.

	Notes and Sources

Information presented in the profile was summarized in December 2006 from a review of state Web sites and reports, and through contacts with state officials. In most cases the profiles were reviewed by state officials; however, it is possible that states have implemented strategies that are not reflected in this profile.

² The profile only includes Medicaid and SCHIP waivers intended to make comprehensive expansions to the uninsured. At this time, the profiles do not include Family Planning, Pharmacy Plus waivers, or long-term care waivers.

³ Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2005 and 2006 Current Population Survey.