Medicare Advantage Plans in Virginia

Medicare Advantage plans are an alternative to Original Medicare, offered by Medicare-approved private insurance companies. These plans include Part A (hospital) and Part B (medical) benefits. Most also include Part D (prescription drug coverage) and may offer added benefits like dental, vision, hearing, and fitness programs.

Medicare Eligibility

To enroll in a Medicare Advantage plan, you must first sign up for Original Medicare (Parts A and B). Most people become eligible for Medicare enrollment at age 65, although individuals with certain disabilities, ALS, or ESRD may qualify earlier. Key enrollment periods include Initial, General, and Special Enrollment, and penalties may apply for late enrollment or if you don’t qualify for premium-free coverage.

What Types of Medicare Advantage Plans Are Available in Virginia?

Virginia offers the following MA plan types:

• Health Maintenance Organizations (HMOs): Require in-network care and referrals for specialists.
• Preferred Provider Organizations (PPOs): Allow out-of-network care at higher costs and usually don’t require referrals.
• Private Fee-for-Service (PFFS) Plans: Accept any provider who agrees to the plan’s terms; some have networks.
• Special Needs Plans (SNPs):
  • C-SNPs: For chronic conditions like diabetes, HIV/AIDS, or cardiovascular disease.
  • I-SNPs: For individuals living in institutions or needing nursing care.
  • Dual Eligible Special Needs Plans (D-SNPs): For people eligible for both Medicare and Medicaid. These plans may offer added services like drug coverage, dental care, and care coordination.
• Medical Savings Accounts (MSAs): Combine a high-deductible plan with an MSA funded by your insurer.

What Are Your Prescription Drug Options with Medicare Advantage?

Most Medicare Advantage plans include Part D drug coverage. Exceptions include MSAs and some PFFS plans. If your MA plan doesn’t cover drugs, you may:

• Enroll in a separate Part D plan (only allowed for certain plan types)
• Incur a late enrollment penalty if you delay coverage and don’t have creditable prescription insurance

How Do You Choose a Medicare Advantage Plan?

Before choosing a plan, it’s important to understand Medicare Advantage costs. Consider the following:

• Premiums: Many MA plans offer $0 premiums, while others charge a monthly fee.
• Deductibles, Coinsurance & Copays: Know what you’ll pay out of pocket for medical services.
• Out-of-Pocket Maximums: Limits how much you spend each year on healthcare.
• Extra Benefits: Look for plans offering dental, vision, hearing, telehealth, gym memberships, or over-the-counter (OTC) allowances.

When and How Do You Enroll in a Medicare Advantage Plan?

You can enroll in Medicare during specific enrollment periods:

• Initial Enrollment: 3 months before to 3 months after your 65th birthday month.
• Annual Open Enrollment (Oct 15–Dec 7): Join, switch, or drop an MA plan.
• General Enrollment (Jan 1–Mar 31): For those enrolling in Medicare Part B.
• Medicare Advantage Open Enrollment (Jan 1–Mar 31): Switch MA plans or return to Original Medicare.
• Special Enrollment Periods: Triggered by qualifying life events such as:
  • Moving out of your plan’s area
  • Losing employer/union coverage
  • Plan termination
  • Eligibility for a C-SNP

What If You Want to Change Your Medicare Advantage Plan?

You can switch plans during:

• Annual Open Enrollment (Oct 15–Dec 7)
• Medicare Advantage Open Enrollment (Jan 1–Mar 31)

Understanding Medicare Advantage Star Ratings

The Centers for Medicare & Medicaid Services (CMS) rates plans using a 5-star system. Learn more about CMS star ratings:

• ★★★★★ Excellent
• ★★★★ Above average
• ★★★ Average
• ★★ Below average
• ★ Poor performance

These ratings help you compare plan quality, coverage, customer service, and health outcomes.

What Are Medicare Resources in Virginia?

Virginia provides several support services:

• Virginia Insurance Counseling and Assistance Program (VICAP): Free counseling for Medicare beneficiaries.
• Senior Medicare Patrol (SMP): Protects beneficiaries from Medicare fraud and billing errors.
• State Corporation Commission: Handles insurance-related complaints.
• Virginia Medicaid (Cardinal Care): For low-income residents. Call 1-855-242-8282 for help. Learn more about the differences between Medicare and Medicaid.

Other Medicare Plan Options to Help with Out-of-Pocket Costs

You may also consider Medicare Supplement Plans, or Medigap, which help cover deductibles, coinsurance, and copayments not paid by Original Medicare.

• Must be enrolled in Medicare Parts A and B
• Best to enroll during your six-month Medigap Open Enrollment Period
• Medigap plans do not cover prescription drugs (you’ll need a separate Part D plan)
• There are 10 standardized Medigap plans; Plans G and N are the fastest-growing
• Medicare Supplement Plan G had the highest enrollment in 2023

Learn more about Medicare Supplement plans in Virginia.

Next Steps

If a Medicare Advantage plan in Virginia is right for you, compare available plans in your area. Review costs, benefits, provider networks, and drug formularies to find the best fit. Be ready to enroll during your eligibility window.