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WV Diabetes Health Home

One of the two Medicaid Health Home programs (i.e. Behavioral Health Health Home and Diabetes Health Home) designed to coordinate health care teams to provide the best care possible to patients living with chronic illnesses, with the goal of increasing provider-patient communication, improved patient health, and reducing excess costs within the health care system.  The WV Department of Health and Human Resources began implementing the Diabetes Health Home in 2017 within 14 counties in West Virginia. ​


Eligible Counties

  1. Boone

  2. Cabell

  3. Fayette

  4. Kanawha

  5. Lincoln

  6. Logan

  7. Mason

  8. McDowell

  9. Mercer

  10. Mingo

  11. Putnam

  12. Raleigh

  13. Wayne

  14. Wyoming

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Steps to enroll as a Diabetes Health Home

1. Identify core team members

  • Provider/Team Lead

    • MD, DO or Advanced Practice Nurse

  • Behavioral Health Specialist

    • Masters or doctoral level

    • Licensed in counseling, psychology or social work​

  • Nurse

    • RN

  • Care Manager

    • RN or behavioral health specialist 

  • Care Coordinator

    • Bachelor’s level

    • Social science with some applicable patient care or counseling experience​

1. Identify eligible patients

Medicaid patients who have been diagnosed with pre-diabetes, diabetes or obesity, as well as being at risk for anxiety or depression​, who receive services from a provider in an eligible county (see map above). 

5. Document patient care coordination.

Document patient care coordination (document in either EHR or KeyPro). See page 7 in the

Health Home Provider Standards PDF.

2. Enroll patients

The Diabetes Health Home is an opt-out consent process meaning that Health Home providers can auto-enroll eligible patients in Health Home.  Patients will then have the option to opt out at any point. 

6. Invoice for service-$51 per month per patient


3. Provide required Health Home services

​For each patient enrolled in Health Home provide:

  1. Comprehensive care management 

  2. Care coordination 

  3. Health promotion 

  4. Comprehensive transitional care and follow-up 

  5. Patient and family support 

  6. Referral to community and social support services 

For more details, see pages 5-7 in the Health Home Provider Standards PDF.

7. Re-certify enrollees/patients in KeyPro every 4 months 

Re-enroll patients in KeyPro every 4 months.  Patients must still be eligible for Medicaid (as well as still at risk for anxiety/depression) to qualify for re-enrollment.

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Eligible Counties

2. Complete the Diabetes Health Home application

The Health Home provider application can be found here:

Health Home Provider Application PDF

Mail completed application to:

Richard D. Ernest, Jr.,

WV DHHR Bureau for

Medical Services

350 Capitol Street, Room 251

Charleston, WV 25301-3706

3. Receive BMS approval

The West Virginia Bureau of Medical Services will review your application and notify you of its approval.

4. KeyPro training

After DHHR BMS approves your application, you will receive a KeyPro Portal account and training.

Steps to implement the Diabetes Health Home

For more information

Visit the WV DHHR Bureau for Medical

Services' Diabetes Health Home Provider Info webpage:


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