The American long-term-care system is largely paid for by Medicaid, and that dynamic is especially pronounced in West Virginia. More than 70% of WV nursing-home residents are on Medicaid — one of the highest shares in the country, reflecting the state’s older demographic, lower median incomes, and limited private LTC insurance penetration.1

WV Medicaid is administered by the Department of Health and Human Resources (DHHR) Bureau for Medical Services. LTC services flow through two main pathways: institutional Medicaid for nursing-facility care, and the Aged & Disabled Waiver (ADW) for home- and community-based services.

Three eligibility tests, in order

1. Medical eligibility

Before financial eligibility is reviewed, your parent must be assessed as needing nursing-facility level of care. WV uses the Pre-Admission Screening and Resident Review (PASRR) process and the Medicaid Level of Care (LOC) assessment. The assessment scores ADLs (activities of daily living), cognitive function, and behavioral indicators, and produces a level-of-care determination.2

Schedule the assessment early; the process can take 2–6 weeks depending on county and assessor availability. The Aged & Disabled Waiver has the additional requirement that the recipient choose the waiver in lieu of institutional care — technically optional but practically necessary for most families who want to keep a parent at home.

2. Income

WV uses an income cap at 300% of the federal SSI benefit rate — approximately $2,901/month for individual Medicaid LTC applicants in 2026. Applicants whose gross monthly income exceeds the cap don’t lose eligibility automatically; they establish a Qualified Income Trust (QIT), sometimes called a Miller Trust, that diverts above-cap income each month.3

3. Assets

The countable-asset limit is $2,000 for an individual applicant. “Countable” excludes:

Countable assets include:

Note for WV specifically: mineral rights and royalty interests are countable assets and are common in WV estates. If your parent owns oil, gas, or coal royalty interests, those count toward the asset limit and often require disclosure and valuation during the application.

The 60-month look-back, in plain English

Like every state, WV reviews any transfer of assets for less than fair-market value made in the 60 months prior to the application. The penalty is calculated by dividing the value of the transfer by WV’s monthly penalty divisor — approximately $9,500/month in 2026.

A $50,000 gift produces roughly a 5-month penalty. The penalty doesn’t start when the gift was made; it starts when the applicant is otherwise eligible for Medicaid (i.e., assets spent down to $2,000, parent in care). That timing is what makes the look-back painful — the penalty hits exactly when the family needs Medicaid most.

The Aged & Disabled Waiver (ADW)

WV’s primary HCBS waiver is the Aged & Disabled Waiver, authorized under §1915(c) of the Social Security Act. ADW services include personal care assistance, homemaker services, transportation, environmental modifications, respite care, and limited adult day services.4

Two ADW features worth understanding:

Spousal protections

When one spouse needs LTC and the other doesn’t, the well spouse (the “community spouse”) is entitled to:

Most one-spouse-needs-care situations can be planned to a non-catastrophic outcome with 12–24 months of lead time. WV’s lower asset base sometimes means the community spouse is already within the CSRA limit, which simplifies the planning — but always verify the analysis with WV counsel before relying on it.

Estate recovery in WV

Federal law requires every state to pursue estate recovery for Medicaid LTC benefits paid on behalf of a recipient age 55 or older.5WV pursues recovery through probate assets — meaning property that passes through the deceased’s probate estate is subject to DHHR’s Medicaid claim. Property passing outside probate (joint tenancy with survivorship, beneficiary designations, properly structured trusts) generally escapes WV estate recovery, though the federal expansion to non-probate assets has been threatened periodically.

Planning around estate recovery is one of the more consequential WV Medicaid planning considerations, especially for families with land or mineral rights they want to preserve for the next generation. Standard tools include life-estate deeds, ladybird deeds (where state law permits — WV recognition is uneven), revocable trusts, and beneficiary designations.

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