Federal rule drastically cuts wellness program in West Virginia

States are prohibited from offering multiple types of Medicaid plans for children, who make up most of the enrollees in the state's novel experiment.

By Doug Trapp — Posted Nov. 12, 2010

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An effort in West Virginia to encourage healthy behavior in certain Medicaid enrollees has been dramatically scaled back by a federal regulation requiring states to offer children a minimum level of benefits.

The Deficit Reduction Act of 2005 gave states the power to offer Medicaid enrollees varying Medicaid benefit levels if the packages had the same actuarial value. As a result, West Virginia limited benefits for healthier enrollees who did not choose to participate in a medical home program known as Mountain Health Choices.

Mountain Health Choices allows West Virginia Medicaid enrollees who promise to follow a wellness plan, undergo regular checkups and listen to doctors' orders to receive enhanced benefits, such as WeightWatchers and smoking cessation programs. Medicaid enrollees who didn't opt for Mountain Health Choices were enrolled automatically into a Medicaid plan with more restrictions than traditional Medicaid, such as limits on prescriptions and mental health services. The program went statewide more than two years ago after beginning as a pilot project in a few counties.

But the novel experiment in Medicaid wellness has lost most of its enrollees -- children. A Dept. of Health and Human Services final rule issued on April 30 -- based on provisions in the national health reform law -- prohibits states from offering multiple types of Medicaid plans for children, said John Law, spokesman for the West Virginia Dept. of Health and Human Resources, the state's Medicaid agency. Of the 170,890 Mountain Health Choices enrollees in June, 151,205 were children. The state has more than 400,000 Medicaid enrollees.

The state can't automatically enroll adults with children on Medicaid in Mountain Health Choices, according to the rule, which took effect July 1. Adults who were automatically enrolled in the program could opt out, Law said. Adults who leave the program will receive traditional, nonrestricted Medicaid benefits. Of the 14,565 adults eligible to opt out, 12,818 had been moved into nonrestricted Medicaid benefits as of Sept. 30.

The state is not fighting the federal rule, Law said. But West Virginia Gov. Joe Manchin has vowed to push for personal responsibility in health programs, including Medicaid. "If you are a healthy person who is financially challenged -- and you need help from the state -- then you're going to have some responsibilities to meet," he told a Wheeling, W.Va., newspaper. (Manchin was elected as a new U.S. senator from West Virginia on Nov. 2.)

Manchin is "simply is not keen on the Mountain Health Choices rule changes and would have liked to have had more collaboration ... and input before they were implemented," Manchin spokesman Melvin Smith wrote in an Oct. 14 e-mail.

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