In 2007 West Virginia redesigned its Medicaid program, including an incentive and “nudging” scheme intended to encourage better health care behaviors and reduce Emergency Department (ED) visits. We use West Virginia Medicaid enrollment and claims data from 2005 to 2010 to examine the impact of this redesign on ED visits. We utilize a difference-in-differences approach with individual and time fixed effects comparing beneficiaries on tradition Medicaid to those who moved to the new Mountain Health Choices (MHC) Program. We find that contrary to intentions, the MHC program increased ED visits.