OBJECTIVES: Hospitalizations for Ambulatory Care Sensitive Conditions also known as preventable hospitalizations can be prevented by proper management in the primary care settings. West Virginia (WV) has highest per person preventable hospitalization cost as compared to other states. The objective of this study is to examine the rates of preventable hospitalizations and patient- and county-level factors that may be associated with preventable hospitalizations among Medicaid beneficiaries with chronic conditions in WV. METHODS: Longitudinal dynamic cohort design with baseline and follow-up years was used.  Patient-level data were obtained from 2007-2010 Medicaid claims files and county-level data were derived from the Area Health Resource File for WV. The study population included non-elderly inpatient users with selected chronic conditions and 24-months continuous fee-for-service enrollment in Medicaid and not enrolled in Medicare (n=2,938). The dependent variable was any preventable hospitalization in the follow-up year and these were identified using the Prevention Quality Indicator software developed by the Agency for Healthcare Research and Quality.  All patient-level (e.g. demographic characteristics, healthcare utilization, and care continuity) and county-level factors (e.g. county level of healthcare infrastructure) were measured during the baseline. Chi-square tests and logistic regressions were used to determine the association between patient- and county-level factors and preventable hospitalizations. RESULTS: In this study population 65% were women, 96.3% were whites; 18.5% had any preventable hospitalizations; 12.2% had chronic and 7.2% had acute preventable hospitalizations. A higher percentage of adults in the age group 35-44 had any preventable hospitalization (22.2%) compared to adults in the age-group 25-34 (14.0%). The results from multivariable analysis suggest that patients living in the counties with higher income were less likely to have acute preventable hospitalizations [AOR=0.48, 95% CI (0.28, 0.83)].   CONCLUSIONS: Economic climate in WV counties may impact the risk of acute preventable hospitalizations.