Summary of Benefits.

Doctor's Office Visits

Physician services related to 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.

Please note that being treated in a hospital emergency room for a non-emergency can result in getting billed for those services.

Urgent Care or After Hours Clinic Visits

Prescription Drugs

Brand and generic drugs are covered, including oral contraceptives. Click here to see the new prescription drug formulary (p.d.f.) or required prescription copayments.

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 2006 Immunization Schedule.

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.

Dental Services

Regular preventive dental services include:

  • dental exams every six months
  • a full-mouth x-ray every 36 months. 

Coverage also includes:

  • sealants and fillings as needed
  • simple extractions
  • treatment of abscesses, including initial visit and follow-up if needed
  • extraction related to an abscess
  • root canal therapy
  • removal of cysts under tooth or gums and x-rays needed to diagnose the condition. 

*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 which will be covered in one visit, you may want to contact Acordia National at 1-800-356-2392.

Oral Surgery

Extraction of impacted teeth, medically necessary ridge reconstruction and orthognathism.

Please note that being treated without physician declaring medical necessity can result in getting billed for those services.

Accident Related Dental Services

Services provided within six months of an accident which make it necessary to restore tooth structure damages due to that accident.

Please note that being treated without physician declaring medical necessity can result in being billed for those services.

Vision Services

This includes annual exams and eyewear. Lenses and frames or contacts are limited to $125. 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.

Vision Therapy

Corrective eye exercise therapy is a covered benefit for children up to $750 per 12-month coverage period.

Please note that being treated without physician declaring medical necessity can result in getting billed for those services.

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.

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

  • height and weight measurement
  • blood pressure checks
  • vision, hearing, and dental screening
  • physical exams
  • developmental/behavioral assessment

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, 3, 4, 6, 9 and 12 months.
  • For children ages one year to eighteen, once a year is recommended. 
  • Download the latest periodic prevention schedule and growth charts.

Mental Health and Chemical Dependency Services

Inpatient, Partial Hospitalization and Day Programs; these are covered when ordered by a licensed provider. There is a limit of 30 days per year for inpatient care and up to 60 days per year for partial hospitalization and day programs.

  • Case Management for Special Needs.

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 prior approval or pre-certification.

For the full listing of all specialized services, you may get a copy of the WVCHIP Summary Plan Description by calling the WVCHIP toll-free Helpline at 1-877-982-2447 or click here (p.d.f.) 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.

End of page, navigation to follow.

Navigation
This is an official website of the State of West Virginia. To contact us by phone, please call 1-877-982-2447. For problems or questions regarding this website, please contact the web administrator.