West Virginia Medicaid Personal Care Services Program

Last updated: March 09, 2024


Overview of West Virginia Medicaid Personal Care Services

West Virginia’s Medicaid Personal Care Program, also called the Personal Care Services Program, or simply, PC Services, is for West Virginians of all ages who require in-home daily living assistance. Intended to assist these persons in continuing to live independently in their homes, program participants receive assistance with their Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). These activities include bathing, dressing, mobility, light housework, meal preparation, eating, and shopping for essentials, such as groceries.

Program participants can live in their own personal home or that of a loved one. PC Services are not generally available to persons residing in adult family care homes (adult foster care homes) or assisted living residences. However, in some cases, the Medicaid Personal Care Program might provide assistance in these settings. However, PC Services cannot replace or duplicate services that are already being provided by the residence.

While many home and community based services (HCBS) Medicaid programs allow program participants to self-direct their own care, specifically allowing them to hire their own caregiver, the Medicaid Personal Care Program does not. Instead, program participants must receive personal care services via a licensed Medicaid personal care agency (provider agency). However, it is possible for a friend or family member to be hired by a provider agency, given they are licensed to provide such care, and then become the paid caregiver of their loved one. Legally responsible persons, such as a spouse, are prohibited from this arrangement.

The Personal Care Program is available through West Virginia’s Regular State Plan Medicaid program. PC Services are an entitlement. This means meeting the state’s Medicaid eligibility requirements guarantees one will receive this type of assistance; there is never a waiting list for program participation.

 Medicaid Waivers vs. State Plan Medicaid
While home and community based services (HCBS) can be provided via a Medicaid Waiver or a state’s Regular Medicaid Plan, HCBS through Medicaid State Plans are an entitlement. This means meeting the program’s eligibility requirements guarantees an applicant will receive benefits. On the other hand, HCBS via Medicaid Waivers are not an entitlement. Waivers have a limited number of participant enrollment slots, and once they are filled, a waitlist for benefits forms. Furthermore, HCBS Medicaid Waivers require a program participant require the level of care provided in a nursing home, while State Plan HCBS do not always require this level of care.


Benefits of West Virginia Medicaid Personal Care Services

Program participants can receive up to 210 hours per month of Personal Care Services. The amount of monthly assistance hours, and the services for which one can receive assistance, is determined based on an individualized care plan. Assistance with the following activities may be provided.

– Bathing / Showering
– Dressing
– Eating
– Essential Shopping – groceries, pharmacy
– Light Housekeeping – i.e., dusting, mopping, changing bed linens, washing dishes, laundry
– Meal Preparation
– Medication Assistance / Reminders
– Mobility
– Personal Hygiene / Grooming – i.e., nails, skin, hair, shaving
– Toileting
– Transferring – i.e., from bed to standing
– Transportation Assistance

The Medicaid Personal Care Program does not pay for room and board for program participants who reside in an assisted living residence or adult family care home.


Eligibility Requirements for West Virginia Medicaid Personal Care Services

PC Services are for West Virginia residents of any age who require assistance with their daily living activities. Additional eligibility criteria follows and is relevant for seniors and adults with disabilities.

 The American Council on Aging provides a quick and easy Medicaid Eligibility Test for WV seniors


Financial Criteria: Income, Assets & Home Ownership

In 2024, the individual applicant income limit is $943 / month. For a married applicant, regardless of if one spouse or both spouses is an applicant, the income limit is $1,415 / month.

 Many home and community based services Medicaid programs allow a non-applicant spouse to retain a larger portion of a couple’s income and assets. West Virginia’s Medicaid Personal Care Program does not. However, the state’s Aged and Disabled Medicaid Waiver, which offers a variety of long-term services and supports, allows a non-applicant spouse a Monthly Maintenance Needs Allowance from their applicant spouse and a Community Spouse Resource Allowance. Furthermore, persons who are eligible for the Aged and Disabled Waiver may simultaneously be able to receive personal care services through the Personal Care Program.

In 2024, the asset limit is $2,000 for a single applicant. For married couples, it is $3,000, regardless of whether one spouse or both are applicants.

Some assets are not counted towards Medicaid’s asset limit. These generally include an applicant’s primary home, household furnishings and appliances, personal effects, and a vehicle.

While there is a 60-month Look-Back Rule in which Medicaid checks past asset transfers of those applying for Nursing Home Medicaid or home and community based services via a Medicaid Waiver, it is not relevant for West Virginia’s Medicaid Personal Care Program.

 To determine if you might have assets over Medicaid’s countable limit, and if so, receive an estimate of the amount, use our WV Medicaid Spend Down Calculator.

Home Ownership
The home is often the highest valued asset a Medicaid applicant owns, and many persons worry that Medicaid will take it. For eligibility purposes, WV Medicaid considers the home to be exempt (non-countable) in the following circumstances.

– The applicant lives in the home or has “Intent” to Return.
– A spouse lives in the home.
– The applicant has a permanently disabled or blind child living in the home.
– The applicant has a minor child (under 21) living in the home.

Unlike other WV Medicaid programs that offer long-term care, the Personal Care Services Program does not have a home equity interest limit for home exemption. Home equity is the current value of the home minus any outstanding mortgage. Equity interest is the portion of the home’s equity value that is owned by the applicant. Learn more about home exemption and when Medicaid can and cannot take the home here.


Medical Criteria: Functional Need

While many Medicaid long-term care programs require an applicant to need a Nursing Facility Level of Care (NFLOC), the Personal Care Program does not. The need for assistance, however, must be “medically necessary”. To make this determination, a registered nurse completes an in-home assessment utilizing the Pre-Admission Screening (PAS). Via the PAS, it must be determined an applicant has 3 functional deficits. Several deficit areas are considered, which include stage 3 or 4 decubitus ulcers (bedsores), the ability / inability to independently complete Activities of Daily Living (ADLs), such as bathing, dressing, walking, eating, and continence, the ability to leave a building if there is an emergency, skilled needs in specific areas (i.e., sterile dressings, tracheostomy, irrigations), and the inability of self-administering medications. While persons with Alzheimer’s disease or a related dementia might meet the functional need for care, a diagnosis of dementia in and of itself does not mean one will do so.

 Learn more about long-term care Medicaid in West Virginia.


Qualifying When Over the Limits

Having income and / or assets over Medicaid’s limit(s) does not mean an applicant cannot still qualify for WV Medicaid. There are a variety of planning strategies that can be used to help persons who would otherwise be ineligible to become eligible. Some of these strategies are fairly easy to implement, and others, exceedingly complex. Below are the most common.

West Virginia has a Medically Needy Pathway to eligibility for Medicaid applicants who have high medical expenses relative to their income. Also known as a Spenddown Program, applicants are permitted to spend “excess” income on medical expenses and health care premiums, such as Medicare Part B, in order to meet Medicaid’s Medically Needy Income Limit. The amount that must be “spent down” can be thought of as a deductible. Once one’s “deductible” has been met, the Personal Care Services Program will pay for personal care services.

When persons have assets over the limits, Irrevocable Funeral Trusts (IFTs) are an option. IFTs are pre-paid funeral and burial expense trusts that Medicaid does not count as assets. Persons may also choose to “spend down” countable assets on assets that Medicaid considers to be exempt (non-countable). Examples include making home reparations and modifications, purchasing home furnishings, and even taking a vacation. Persons may also turn countable assets into an income stream through an annuity. There are many other Medicaid planning strategies available when the applicant has assets exceeding the limit.

Inadequate planning or improperly implementing a Medicaid planning strategy can result in a denial or delay of Medicaid benefits. Professional Medicaid Planners are educated in the planning strategies available in West Virginia to meet Medicaid’s financial eligibility criteria without jeopardizing Medicaid eligibility. Furthermore, while Medicaid’s 60-month Look-Back Rule does not apply for Personal Care Services, it does apply to Nursing Home Medicaid and the Aged and Disabled Waiver Program. As more extensive Medicaid-funded care might be required in the future, it is vital that one not violate the Look-Back Rule. Medicaid planning strategies should ideally only be implemented with careful planning and well in advance of the need for long-term care. However, there are some workarounds, and Medicaid Planners are aware of them. For these reasons, it is highly suggested one consult a Medicaid Planner for assistance in qualifying for Medicaid when over the income and / or asset limit(s). Find a Medicaid Planner.


How to Apply for the West Virginia Medicaid Personal Care Program

Before You Apply

Prior to submitting an application for Personal Care Services, applicants need to ensure they meet the eligibility criteria. Applying when over the income and / or asset limit(s) will be cause for denial of benefits. The American Council on Aging offers a free Medicaid Eligibility Test to determine if one might meet Medicaid’s eligibility criteria. Take the Medicaid Eligibility Test.

As part of the application process, applicants will need to gather documentation for submission. Examples include copies of Social Security and Medicare cards, previous bank statements, proof of income, and copies of life insurance policies, property deeds, and pre-need burial contracts. Unfortunately, a common reason applications are delayed is required documentation is missing or not submitted in a timely manner.


Application Process

To be eligible for the Medicaid Personal Care Program, one must be eligible for WV Medicaid. One can apply online, in-person at their local DHHR office, or via the Customer Service Center at 877-716-1212. Persons can also submit a completed Application for Health Coverage & Help Paying Costs to their local DHHR office.

Persons who are already enrolled in Medicaid can initiate the application process for PC Services by submitting a completed Personal Care Program Medical Necessity Evaluation Request (PC-MNER). Following receipt of the PC-MNER, the applicant will be contacted to schedule an in-home Pre-Admission Screening (functional needs assessment).

Additional information about West Virginia’s Medicaid Personal Care Program can be found here. Persons can also call 866-767-1575 to reach the Bureau of Senior Services’ Medicaid helpline.

The West Virginia Department of Health and Human Resources (DHHR), Bureau of Medical Services (BMS) administers the Personal Care Services Program. The West Virginia Bureau of Senior Services operates it. County DHHR offices determine financial eligibility. A BMS Utilization Management Contractor (UMC) determines functional eligibility. Currently, the UMC is KEPRO.


Approval Process & Timing

The West Virginia Medicaid application process can take up to 3 months, or even longer, from the beginning of the application process through the receipt of the determination letter indicating approval or denial. Generally, it takes one several weeks to complete the application and gather all of the supportive documentation. If the application is not properly completed, or required documentation is missing, the application process will be delayed. Based on federal law, Medicaid offices have up to 45 days to review and approve or deny one’s application (up to 90 days for disability applications). Despite the law, applications are sometimes delayed even further.

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