Member Responsibilities
The responsibilities of Medicaid members include, but are not limited to, the following:
- Notifying providers in a timely manner if unable to keep an appointment.
- Notifying providers promptly of changes in Medicaid coverage.
- Notifying providers of any changes in other insurance coverage, such as Medicare or private health insurance.
- Presenting a valid Medicaid identification card at each visit.
- Forwarding money or denials received from other insurance payers to their Medicaid providers.
- Informing their local WV DHHR office of any changes in address, income, etc.
- Paying providers required co-pays, if applicable.
Member Liability
A provider must accept Medicaid payment as payment in full for covered services. A claim is considered paid in full even when the actual Medicaid payment is zero dollars. Providers are prohibited from imposing any additional charges on the member above the Medicaid allowable reimbursement amount. This does not include Medicaid co-payments, if applicable.
Medicaid members
must not be billed, or otherwise held responsible, for:
- Payments denied for provider error. For example:
- Claims filed more than one year after date of services
- Wrongful billing or missing information
- Billings denied because the provider did not:
- Follow procedures
- Obtain prior approval from Medicaid or the managed care provider, if applicable.
- Notify the member before the service is provided that is not covered by Medicaid.
- Charges remaining after payments by insurance or Medicaid are made.
- Fees for missed appointments
Member Responsibilities for Certain Changes
Prior to services being rendered by a provider, the provider must inform or give notice to the member that the provider will not bill Medicaid for the services and the member will be responsible for the charges. Medicaid members, if given prior notice,
may be billed for:
- Services received after Medicaid benefits are exhausted
- Services not medically necessary that the member elected to receive
- Services not covered by Medicaid that the member elected to receive
- Non-emergent services not prior-approved, if applicable
- Convenience items not required for medical care
- Services rendered when the member is not eligible
- Services provided when the member refuses to use other available insurance. The exception to this is the non-methadone medication assisted treatment.
Medicaid Card Information
If you are also enrolled in Managed Care, you will receive a card from that plan, as well.
- Medicaid Member Card: When you qualify as a Medicaid Member, you get a Medicaid card.
- Only you can use your card. It is against the law to let anyone else use it.
- Important Information about your card. Please be sure to keep it in a safe place so you will have it when you need it. If you lose your card, you may ask for another one by:
- Calling your case worker at your local Department of Health and Human Resources (DHHR) office, or
- Calling the DHHR Customer Service Center at 1-877-716-1212.
If you, or someone in your household, have a medical appointment and you cannot find your Medical Card, you can get a Letter of Creditable Coverage. This letter is only good for the day it is printed. Go to
www.wvmmis.com and click "Sign In" at the top of the page. Enter your username and password.
If you do not have internet access, your health care provider can confirm your Medicaid eligibility.
If you have any questions, contact your case worker or the DHHR Customer Service Center at 1-877-716-1212.
You may apply for Medicaid benefits by:
- Going to the Health Insurance Marketplace at
www.Healthcare.gov.
- Contacting the Federal Marketplace call center at 1-800-318-2596.
- Going online to
www.wvinROADS.org.
- Visiting your county Department of Health and Human Resources office Monday through Friday 8:30 a.m. to 5:00 p.m., except on state holidays. For your convenience you may call for an appointment. A list of offices can be found at
www.dhhr.wv.gov/bcf or you can call the DHHR Change Center at 1-877-716-1212.
Medicaid Member Handbook not created yet.
"Your Guide to Medicaid" and other information about your Medicaid benefits can be found in the Member section of the WV Bureau for Medical Services website at www.dhhr.wv.gov/bms.