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Covered Services

Dental Services

The WVCHIP Benefit Plan covers a full range of dental services.  WVCHIP Gold Plan and WVCHIP Blue Plan members have no copayments for dental services, but WVCHIP Premium members have $25.00 copays for some non-preventive procedures, with a maxiumum copayment of $100.00 per child or $150.00 per family per benefit year.  Also, some services require precertification before the plan will cover them.  (See the WVCHIP Summary Plan Description's (SPD) section on "Dental Services" for more details, or the WVCHIP Dental Guide.)

Regular preventive dental services include*:

  1. dental exams every six months;
  2. a full-mouth x-ray every 36 months;
  3. sealants (1 per tooth/per 3 yrs.);
  4. treatment of abscesses, including initial visit and follow-up if needed;
  5. space maintainers;
  6. bitewings.  See dental provider Guide for service limits;
  7. cleaning and fluoride treatments every six months;
  8. other x-rays (covered in connection with another service).

*[Please Note: If you are unsure of how long it has been since the child's last exam, or how many different types of x-rays will be covered in one visit, you may want to contact DXC Technologies at 1-800-479-3310.]

Copays for Premium members are assessed on the following services:
Restorative
Endodontics /Root canals /Periodontics
Surgery /Extractions
Other Basic Services
Prosthodontics
Restorative Services
Orthodontic Services

Oral Surgery

Only covered for Extraction of impacted teeth, medically necessary ridge reconstruction and orthognathism are covered under the medical plan.

Accident-Related Dental Services

The Least Expensive Professional Acceptable Alternative Treatment (LEPAAT) for accident-related dental services is covered when provided within six (6) months of an accident and required to restore damaged tooth structures.  The initial treatment must be provided within 72 hours of the accident.  Biting and chewing accidents are not covered.  Note:  For children under the age of 16, the six-month limitation may be extended if a treatment plan is provided within the initial six months and approved by Healthsmart.

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.

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.

Note:  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 0ral 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 Advisory Committee on Immunizations. The Plan covers immunizations as part of an associated office visit to a doctor enrolled in the Vaccine for Children’s program. Click here for the current Immunization Schedule for Ages 0-6 years, or the Current Immunization Schedule for Ages 7-18 years.  Also newly provided is the Adult Immunization Schedule.
See 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

This includes annual exams and eyewear. Lenses and frames or contacts are limited to $125 per year. The eyewear cost may exceed $125 with medical necessity and prior approval. The office visit and examination are covered in addition to the $125 eyewear limit.  Families are responsible to pay the difference between the total charge for eyewear and the $125 allowance for lenses and frames that do not meet medical necessity and are not preauthorized.

Vision Therapy

Medical necessity review is required beyond 20 visits for corrective eye exercise therapy.  Maintenance therapy is not a covered benefit by WVCHIP.

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.   See SPD for more information.

Well Child Care (see Preventive Care)

The American Academy of Pediatrics recommends routine office visits to check your child’s health and development until he or she reaches adulthood. Since West Virginia children are expected to have a Well child or HealthCheck exam before entering public preschool classes or kindergarten, providers are encouraged to use the West Virginia HealthCheck screening forms to show that the complete prevention checkup and screens were performed.  Parents should ask for a copy of the HealthCheck exam form to give to school officials.

These routine check-ups include, but are not limited to:

  1. height and weight measurement;
  2. blood pressure checks;  
  3. physical exams;
  4. developmental/behavioral assessment;
  5. age appropriate immunizations as indicated by a physician;
  6. objective vision & hearing screening BMI calculation;
  7. lead risk screen;
  8. one physician office visit a year for a preventive check-up is covered for all insured children ages 2 through 18.  Infants under two are covered for more frequent checkups as recommended by the AAP guidelines.

The recommended periodic schedule for these visits is:
For children from birth to one year, visits are recommended as follows: 2-4 weeks and at 2, 4, 6, 9, 12, 15, 18 months.  Objective developmental screening tool is to be administered to a child at the 9, 18 & 30 month well child visit.

Mental Health and Substance Use Disorder Services

Inpatient hospitalization,chemical dependency and substance abuse services; outpatient mental health, outpatient partial hospitalization day programs, chemical dependency and substance abuse services are covered when ordered by a licensed provider.  Chronic or extreme medical conditions will be assigned to a case manager, and based on the conditon; the nurse case manager may recommend continued visits.  Coverage for services beyond 26 visits is not covered without medical necessity review and prior authorization.  (See the "What Is Covered Under the Plan?, Mental Health Services" section of the SPD for more information.)

Case Management for Special Needs

Medical case management is provided through KEPRO'S medical case management program.  KEPRO must be notified for medical case management for home health care; skilled nursing facility services; and rehabilitation services.  They may be contacted at 1-888-571-0262.  (See "Medical Case Management" section of the SPD for more information.) 

Other Specialized Services

Many other specialized services such as Allergy Services, Ambulance, Cardiac Rehabilitation, Durable Medical Equipment, Physical Therapy, Speech Therapy, Occupational Therapy, Organ Transplants, etc. are covered. Many specialized services require pre-certification.

For the full listing of all specialized services, please see the WVCHIP Summary Plan Description.  Click here to view it.

Non-Covered Services

There are some types of services not covered such as acupuncture, Christian science treatments, custodial care or respite care, some dental services, electroconvulsive therapy, routine foot care, etc.

For the full listing of non-covered services, please see the WVCHIP Summary Plan Description.