Benefits & services

We manage your covered benefits by:

  • Working with your doctor to decide what care is needed
  • Deciding what care is covered

A health plan doctor or provider will provide your care. You an choose your own personal doctor as long as it is in our network. We contract with a select network of providers for your care. We check our doctors and hospitals often to make sure you get the care you deserve. There may be times when a network provider can is not available to give you the care you need. If this happens, you may need to go out of the network for the care. We must approve this first.

We only cover care or supplies that are medically needed by you. We decide medical need by looking at the accepted standards of care. We decide whether the care meets these standards.

Your Member Handbook gives you more information on covered benefits, including things that are excluded from coverage.

Member Co-Payments
Some services require the member to pay a co-payment. Co-payments are based on the member’s household income. The chart below lists the co-payments the member needs to pay for each service. The co-payment amount may be different for each Federal Poverty Level (FPL). 

Medical Co-Payments Chart

Service

TIER 1

Up to 50.00% FPL

TIER 2

50.01-100.00% FPL

TIER 3

100.01% FPL and above

Inpatient Hospital (Acute Care 11x)

$0

$35

$75

Office Visit (Physicians and Nurse Practitioners)

(99201-99205, 99212-99215 only for office visits with new and established patients based on level of care.)

$0

$2

$4

Non-Emergency use of Emergency Department – Hospital only (Lowest level (99281) of Emergency Room visits in hospitals. The definition of an emergency department visit for the evaluation and management of a patient, which requires these 3 key components: A problem focused history; A problem focused examination; and straightforward medical decision making.)

$8

$8

$8

Any outpatient surgical services rendered in a physician’s office, ASC or Outpatient Hospital excluding emergency rooms.

$0

$2

$4

 

Pharmacy Co-Payments Chart

Total Allowed Charge

Co-payment

$0.00-$5.00

$0.00

$5.01-$10.00

$0.50

$10.01-$25.00

$1.00

$25.01-$50.00

$2.00

$50.01 and above

$3.00

 

Maximum Out of Pocket (OOP)
Each calendar year quarter, Medicaid members will have a maximum OOP payment. The OOP is the most the member will be required to pay in any given quarter regardless of the number of healthcare services they receive.

Out of pocket maximum chart

Tier Level

Out of Pocket Maximum

1 (Up to 50.00% FPL)

$8

2 (50.01-100.00% FPL)

$71

3 (100.01% FPL and above)

$143

 

Co-payments will NOT be collected for:

  • Family planning services
  • Emergency services
  • 72-hour emergency supply of medication
  • Following pharmacy services: diabetic testing supplies, syringes and needles, and home infusion supplies approved by the Department
  • Members under age 21
  • Pregnant women (including the 60-day postpartum period following the end of pregnancy)
  • American Indians and Alaska Natives
  • Members receiving hospice care
  • Members in nursing homes
  • Any additional members or services excluded under the State Plan authority
  • Members who have met their household maximum limit for the cost-sharing obligations per calendar quarter

 Other service may also not require a co-payment. Contact Member Services at 1-888-348-2922 if you have any questions. 

If you have medical transportation needs (not relating to an emergency) please call MTM at 1-844-549-8353 or visit their website.

Hours of operation: Monday-Friday 8 a.m. - 6 p.m. (EST)

Phone number: Member Services: 1-888-983-4693 (TYY) 1-800-508-6975

Website: Scion Dental

Dental Benefits (Child)
Children up to 21 years of age are eligible for dental checkups. The benefits for children under age 21 have not changed. Please read your Member Handbook. It gives more facts on covered benefits. Scion Dental is the dental provider for Aetna Better Health of West Virginia children. If you need to talk to Scion Dental, call Scion Dental Customer Service at 1-888-983-4693 (TYY) 1-800-508-6975 or visit their website.  A Scion Dental representative can help you with benefit questions and finding a dentist near you.