WVCHIP was created to help working families who don’t have health insurance for their children. Keeping your kids healthy is important, and one of the best ways to do that is by ensuring they receive regular medical care. Children who get proper care are more likely to stay healthy and succeed in school.
Services covered by WVCHIP include:
- Doctor visits
- Check-ups
- Hospital visits
- Immunizations (Shots)
- Prescriptions
- Maternity Benefits
- Tests and X-rays
- Dental care
- Vision care
- Emergency care
- Mental Health
- Diabetic supplies
- Urgent Care or After Hour Clinic Visits
- Case Management for Special Needs
- And more
Click here for a complete summary of Covered Services.
WVCHIP Copay and Premium Information
When your child visits the doctor or fills a prescription, there may be a small fee, called a copay, for some services.
- WVCHIP Gold and WVCHIP Blue: No copays for check-ups, dental care, vision care, or generic prescriptions.
- WVCHIP Premium Plan: Covers the same medical and prescription services as Gold and Blue, but requires a monthly premium. Most non-preventive dental procedures have a $25 copay.
WVCHIP provides a full range of dental services. For details about vision or dental coverage, refer to the Summary Plan Description (SPD) in the Vision Services and Dental Services sections.
Learn more about copayments here.
Check if your family is eligible for WVCHIP here.
Dental Services
WVCHIP covers a full range of dental services:
Copays:
- Gold & Blue Plan members: No copays for dental services.
- Premium Plan members: $25 copays for some non-preventive procedures, with a maximum of $100 per child or $150 per family per benefit year.
Precertification: Some dental services require precertification. Refer to the WVCHIP Summary Plan Description (SPD) under “Dental Services” or the Dental Provider Guide for details.
Preventive Services (Regularly Covered):
- Dental exams every six months
- Full-mouth x-ray every 36 months
- Sealants (1 per tooth, every 3 years)
- Treatment of abscesses, including follow-up
- Space maintainers
- Bitewings (see Dental Provider Guide for limits)
- Cleanings and fluoride treatments every six months
- Other x-rays as needed in connection with another service
Tip: If unsure about the timing of exams or x-rays, contact Gainwell Technologies at 1-800-479-3310.
Copays for Premium Members Apply To:
- Restorative services
- Endodontics / Root canals / Periodontics
- Surgery / Extractions
- Other basic services
- Prosthodontics
- Orthodontic services (limited coverage; see SPD)
- Oral surgery (covered for impacted teeth extraction, medically necessary ridge reconstruction, or orthognathism under the medical plan)
Accident-Related Dental Services:
- Covered if provided within six months of an accident to restore damaged tooth structures. Initial treatment must occur within 72 hours.
- For children under 16, the six-month limit can be extended with an approved treatment plan.
Emergency Dental Services:
- Medically necessary adjunctive services, such as sedation, general anesthesia, and use of outpatient or inpatient surgical facilities, are covered when required to provide optimal therapeutic or preventive oral care.
Important: Services provided without physician-declared medical necessity may result in a bill to the patient.
Doctor's Office Visits
- Physician services related to well child visits, treatment of an illness, injury or medical condition.
- Some periodic physicals are covered (See Well Child Care).
Hospitalization
- Confinement in a hospital including semi-private room, special care units, related services and supplies.
- Prior authorization is required for all admissions to a facility.
Please note that being treated in a hospital emergency room for a non-emergency can result in getting billed for those services., as well as a $35.00 co-pay for WVCHIP Blue & Premium Plans.
Urgent Care or After Hours Clinic Visits
- A visit to an urgent care or after hour's clinic is treated as a physician visit for illness.
Copayments are required for all non-medical home visits, including urgent care and after hour clinic visits. See "Copayments" section of the SPD.
Prescription Drugs
- With mandatory generic substitution, including oral contraceptives.
- Click here to see the current WVCHIP Prescription Drug Formulary.
Brand name drugs require a prior authorization.
Immunizations
All age-appropriate vaccines through age 18 are covered as recommended by the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunizations. WVCHIP covers immunizations as part of an associated office visit to a doctor enrolled in the Vaccines for Children (VFC) program.
- Click here for the current Immunization Schedule for Ages 0-6 years
- Click here for the current Immunization Schedule for Ages 7-18 years
- Click here for the current Adult Immunization Schedule
- Click here to see the Summary Plan Description (SPD) for covered immunizations for pregnant members 19 and over.
WVCHIP purchases vaccines from the State’s Vaccines for Children (VFC) program. This program allows physicians to provide free vaccines to children. Members should receive vaccinations from providers that participate in this program. Since providers outside of West Virginia cannot participate in the VFC program, vaccinations from out-of-state providers will not be covered.
If your doctor does not participate in VFC, then vaccinations can be obtained at your local health department.
Vision Services
WVCHIP covers annual eye exams and eyewear for children.
- Lenses and frames or contacts are covered up to $125 per year.
- Costs exceeding $125 may be covered if medically necessary and approved in advance.
- Office visits and eye exams are covered in addition to the $125 eyewear limit.
- Families are responsible for paying any difference if eyewear costs exceed the allowance and medical necessity or prior approval is not met.
Vision Therapy
Medical necessity review is required beyond 20 visits for corrective eye exercise therapy. Maintenance therapy is not a covered benefit by WVCHIP.
Please note that being treated without physician declaring medical necessity can result in getting billed for those services.
Maternity Benefits
WVCHIP provides coverage of maternity-related professional and facility services, including prenatal care, midwife services and birthing centers beginning July 1, 2019. If a member is pregnant at the time of turning 19 and aging out of WVCHIP coverage, the member needs to contact DHHR to be evaluated for WVCHIP pregnancy coverage. Contact your DHHR County Field Officer.
- Click here to see the Summary Plan Description (SPD) for more information.
Well Child Care (Preventive Care)
Routine check-ups are essential to track your child’s health and development. The American Academy of Pediatrics recommends regular office visits from birth through adulthood.
In West Virginia, children are expected to have a Well Child or HealthCheck exam before starting public preschool or kindergarten. Providers use HealthCheck screening forms to document that all preventive screenings were completed. Parents should request a copy of the form to share with schools.
Routine check-ups may include:
- Height and weight measurements
- Blood pressure checks
- Physical exams
- Developmental and behavioral assessments
- Age-appropriate immunizations
- Vision and hearing screenings
- BMI calculation
- Lead risk screening
Coverage:
- One preventive visit per year is covered for children ages 2–18.
- Infants under 2 are covered for more frequent check-ups as recommended by AAP guidelines.
Recommended visit schedule (birth to 1 year):
- 2–4 weeks, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months
Developmental screenings:
- Objective developmental screenings are recommended at 9, 18, and 30 months.
Mental Health and Substance Use Disorder Services
WVCHIP covers a range of mental health and substance use services when ordered by a licensed provider, including:
- Inpatient hospitalization
- Chemical dependency and substance abuse services
- Outpatient mental health services
- Outpatient partial hospitalization/day programs
Children with chronic or severe medical conditions may be assigned a case manager. A nurse case manager may recommend continued visits based on the child’s condition.
Coverage for services beyond 26 visits requires medical necessity review and prior authorization.
For more details, see the Mental Health Services section under What Is Covered Under the Plan? in the WVCHIP Summary Plan Description (SPD).
Case Management for Special Needs
Medical case management is available through KEPRO. They help coordinate care for children who need:
- Home health care
- Skilled nursing facility services
- Rehabilitation services
Contact KEPRO at 1-888-571-0262 to request case management.
For more details, see the Medical Case Management section of the WVCHIP Summary Plan Description (SPD).
Other Specialized Services
WVCHIP also covers many specialized services, including:
- Allergy services
- Ambulance
- Cardiac rehabilitation
- Durable medical equipment (DME)
- Physical, occupational, and speech therapy
- Organ transplants
Many of these services require pre-certification. For a full listing, refer to the WVCHIP Summary Plan Description.
Non-Covered Services
Some services are not covered by WVCHIP, including:
- Acupuncture
- Christian Science treatments
- Custodial or respite care
- Certain dental services
- Electroconvulsive therapy (ECT)
- Routine foot care
For a complete list of non-covered services, see the WVCHIP Summary Plan Description.
