Mountain Health Trust benefits and services 

• Adults twenty-one (21) and older. Includes diagnostic, preventive, and restorative services. Services also include emergency procedures to treat fractures, pain, or infection. Non-emergency coverage limited to $2,000 per two-year budget period per member.
• Children under age twenty-one (21). Includes emergency, non-emergency, and orthodontic services.

• Post-Stabilization Services. Includes care after an emergency health condition is under control. Care provided in a hospital or other setting.
• Emergency Transportation. Includes ambulance and air ambulance. Out of state needs prior authorization. To call for emergency transportation, dial 911.

• Family Planning. Includes all family planning providers and services. No referral needed for out-of-network providers. Prior authorization is not required.
• Sterilizations. Covers sterilizations for those who are age twenty-one (21) and older and not in an institution or considered mentally incompetent.
• Hysterectomies, pregnancy terminations, and infertility treatments. Not covered.

Includes services given at member’s residence. This does not include a hospital nursing facility, ICF/IDD, or state institutions. Some suppliers have service limits.

Includes nursing care, physician services, medical social services, short-term care, durable medical equipment, drugs, biologicals, home health aide, and homemaker. Requires physician certification. For adults ages twenty-one (21) and older, rights are waived to other treatment services related to the terminal illness.

• Inpatient. Includes all inpatient services (including bariatric and corneal transplants). Transplant services must be in a center approved by Medicare and Medicaid. Adults in institutions for mental diseases and some behavioral health inpatient stays are not included.
• Outpatient. Includes preventive, diagnostic, therapeutic, all emergency services, and rehabilitative medical services.

• Maternity Care. Includes prenatal, inpatient hospital stays during delivery, and postpartum care. Home birth is not covered.
• Right From The Start. Includes prenatal care and care coordination. No prior authorization needed.

• Primary Care Office Visits and Referrals to Specialists.
• Physician Services. Certain services may need prior authorization or have service limits. May be delivered through telehealth.
• Drugs. Certain drugs covered under the medical benefit may need prior authorization or have rules or limits. A list of drug policies outlining these rules and limits can be found here: Medication Policies. A physician may request a prior authorization for your drug, or you may contact Member Services.
• Laboratory and X-Ray Services. Includes lab services related to substance use disorder (SUD) treatment. A physician must order the services, and certain procedures have service limits.
• Clinics. Includes general clinics, birthing centers, and health department clinics. Vaccinations are included for children.

• Nurse Practitioner Services. Some procedures have service limits.
• Private Duty Nursing. Includes twenty-four (24)-hour nursing care (not covered for adults ages twenty-one (21) years and over). Prior authorization may be needed.

• Federally Qualified Health Centers. Includes physician, physician assistant, nurse practitioner, and nurse midwife services.
• Prosthetics. Customized special equipment is considered. Certain procedures have services limits or need prior authorization.
• Durable Medical Equipment. Covered in nursing facilities and intermediate care facilities for individuals with intellectual/developmental disabilities (ICFs/IDD). Customized special equipment is considered. Certain procedures have services limits or need prior authorization.
• Ambulatory Surgical Care. Includes services and equipment for surgical procedures. Physician services; lab and x-ray; prosthetic devices; ambulance; leg, arm, back, and neck braces; artificial limbs; and DME are not covered.
• Organ and Tissue Transplants. Corneal transplants only.
• Gender Affirmation for Gender Dysphoria. Procedure that aligns an individual’s biological sex with their gender identity. Adults must be twenty-one (21) years or older prior to being considered for the procedure. Prior authorization is required.

• Early and Periodic Screening, Diagnosis, and Treatment (EPSDT). Includes health care services for any medical or psychological condition discovered during screening (for children under age twenty-one (21) only).
• Tobacco Cessation. Includes therapy and counseling and Quitline services. Guidance and risk-reduction counseling covered for children.
• Sexually Transmitted Disease Services. Includes screening for a sexually transmitted disease from your PCP or a specialist in our network.

• Physical Therapy. Twenty (20) visits per year (combined for physical and 
  occupational therapy).
• Occupational Therapy. Twenty (20) visits per year (combined for physical and 
• Occupational therapy).
• Speech Therapy. Habilitative and rehabilitative services including hearing aid evaluations, hearing aids and supplies, batteries, and repairs for children under age twenty-one (21). Some procedures have service limits or need prior approval.
• Chiropractor Services. Includes radiological exams and corrections to subluxation. Certain procedures have service limits.
• Pulmonary Rehabilitation. Includes procedures to increase strength of respiratory muscle and functions.
• Cardiac Rehabilitation. Includes supervised exercise sessions with electrocardiograph monitoring.
• Inpatient Rehabilitation. Includes inpatient rehabilitation services and general medical outpatient services that meet the certification requirements.

• Podiatry. Includes treatment of acute conditions for children and adults. Includes some surgeries, treatment of fractures and other injuries, and orthotics. Routine foot care is not covered.
• Handicapped and Children with Special Health Care Needs Services. Includes coordinated services and limited medical services, equipment and supplies.

Includes eye exams, treatment, lenses, frames, and repairs for children under twenty-one (21) years of age. Includes medical treatment, one pair of glasses after cataract surgery, and contact lenses (for certain diagnosis) for adults twenty-one (21) years of age and older. Does not cover prescription sunglasses or designer frames.

Well-child visits, also called Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) services, are important doctor visits that help make sure children stay healthy. In West Virginia, HealthCheck is the name for the EPSDT program.

HealthCheck is for children and young adults age 20 and younger who get Medical Assistance. It covers all necessary and preventive health care services. Your child’s doctor provides both sick and well-care visits at no cost to you.  

Some services covered by HealthCheck include:

• Physical exams 
• Lab tests 
• Eye exams 
• Shots (Immunizations) 
• Hearing tests 
• Dental care 
• Mental health screenings
• Health education 
• Overall health and childhood development  

These check-ups and tests help find health problems early. Your child’s doctor can find and treat any health issues before they become more serious.

To schedule a well-child visit, call your child’s doctor or Member Services. If you need a ride to your appointment or help scheduling, just ask. Transportation services are also available at no cost to you.  

Getting Ready for Adult Care

If you receive HealthCheck services, we want to help you prepare for adult healthcare as you get older.

A Care Coordinator at Highmark Health Options will keep track of your age and will contact you to offer support. Your coverage or eligibility might change as you get older. Our goal is to tell you and your parents/guardians/caregivers about these changes. We will also help update your care plans ahead of time so your services continue without interruption.

This process starts around age 17 and continues until age 20. We will help you get ready for adult health care services.

For more information, visit the WV HealthCheck website.