If you’re eligible for Original Medicare, or Medicare Part A (hospital insurance) and Part B (outpatient insurance), you may have noticed it doesn’t include coverage for prescription drugs. Original Medicare also doesn’t limit your out-of-pocket medical expenses each year.
Another option in Virginia is a Medicare Advantage (MA) plan, or Medicare Part C. These plans are run by private health insurance companies but are required to provide the same basic coverage as Original Medicare. Unlike Original Medicare, most MA plans also cover prescription drugs and limit your annual expenses.
What You Need to Know
Medicare Advantage plans are run by private insurance companies but provide the same basic coverage as Original Medicare.
Many MA plans include coverage for prescription drugs.
You can join a Medicare Advantage plan when you enroll in Original Medicare.
What Types of Medicare Advantage Plans Are Available?
Most Medicare Advantage plans in Virginia use a network of doctors and medical facilities to lower the cost of your care. Common plan types include:
- Health Maintenance Organization (HMO): Except in certain emergencies, these plans often require you to visit an in-network provider for care. If you go outside the network, you may have to pay more out-of-pocket. You’ll also need to choose a primary care physician (PCP) for regular care and referrals to specialists.1
- Preferred Provider Organization (PPO): You can visit any doctor you want, but going to an in-network provider may cost less out-of-pocket. You won’t need to pick a PCP.
- Special Needs Plans (SNP): You’re eligible for an SNP if you have certain health conditions.2
- Chronic Condition SNP (C-SNP): You can join this plan if you’re diagnosed with a chronic condition, such as diabetes or cardiovascular disease.
- Institutional SNP (I-SNP): You’re eligible if you live in a nursing home or other institution, or if you require in-home nursing care.
- Dual-Eligible SNP (D-SNP): These plans are available if you’re eligible for both Medicare and Medicaid.
- Private Fee-for-Service (PFFS): These plans don’t require a PCP. Your plan provider will determine how much to pay doctors for services, as well as the amount you’ll pay when you get care.
- Medicare Medical Savings Accounts (MSA): These are high-deductible health insurance plans that use an MSA to cover out-of-pocket expenses.
Most Medicare Advantage plans also offer vision and dental coverage.
What Are Prescription Drug Options with Medicare Advantage?
Medicare Part D, or coverage for prescription drugs, isn’t included in Original Medicare. However, most Medicare Advantage plans in Virginia cover prescription medications without the need for a separate Part D plan.
You’ll want to check a plan’s drug formulary, or list of covered medications, to make sure your prescriptions are covered before you sign up for a plan.
How Do You Choose Medicare Advantage Plans?
Weigh an MA plan’s costs and benefits when comparing plans in Virginia, such as:
- Premiums: This is the monthly cost of your plan, in addition to the Medicare Part B premium ($148.50 for most people in 2021). Zero-premium plans may also be available, but you might pay more out-of-pocket in deductibles, copays or other costs.
- Other Costs
- Deductible: The amount you’ll have to pay out-of-pocket for care before your plan starts paying each year.
- Coinsurance: Your out-of-pocket portion of the cost of a service or procedure, usually a percentage of the total cost.
- Copay: A fixed price for specific medical services.
- Out-of-Pocket Maximum: Your annual limit on out-of-pocket medical expenses. This usually doesn’t include premiums.
- Plan Benefits
- Vision: Coverage for services such as eye exams or frames.
- Dental: Covers services like teeth cleaning or regular checkups.
- Telehealth: Covers remote health services, such as a phone consultation or video office visit.
- Additional Perks: Many MA plans include additional benefits like reimbursement for gym memberships or transportation services.
When and How to Enroll in Medicare Advantage?
You can join Medicare Advantage plans in Virginia once you’ve enrolled in Medicare Part A and B. The best time to enroll in Medicare is during your Initial Enrollment Period, or Open Enrollment Period (OEP). This period starts three months before you turn 65 and ends three months after you turn 65.
Didn’t enroll during your OEP? You can still enroll in Medicare during the General Enrollment Period from January 1 to March 31 each year. If you enroll outside of your OEP, however, you may have to pay late penalties on your Medicare premiums.
Enrollment in Medicare goes through the Social Security Administration. You can sign up online, over the phone, or at your local Social Security office. Once enrolled, you can begin to look for a Medicare Advantage plan.
There are enrollment periods specifically for Medicare Advantage plans, including:
- Initial Enrollment Period: Join an MA plan when you sign up for Original Medicare.
- Medicare Annual Election Period: Join an MA plan during the annual open enrollment period between October 15 and December 7.
- Medicare Advantage Open Enrollment Period: Switch back to Original Medicare or change your MA plan each year from January 1 to March 31.
- Special Enrollment Period: You might be eligible for special enrollment periods if you meet certain criteria, such as:
- You’re moving outside of your plan’s service area.
- You get health insurance from an employer or union.
- You’re losing your coverage, including becoming ineligible for Medicaid.
- Your plan is leaving the Medicare program or is being terminated.
- You’ve been diagnosed with a health condition that’s best served with an SNP.
How Much Do Medicare Advantage Plans Cost in Virginia?
Your location and other factors can change the amount you’ll pay for Medicare Advantage plans in Virginia. The average monthly cost of an MA plan in Virginia is $19.60.3
A plan in Richmond or Norfolk, for example, could cost between $0 and $86 per month.4 Remember that your premium is only one cost of an MA plan. You should also consider any deductibles, coinsurance or other costs you might have.
You’ll save money on an MA plan by using in-network providers.
What If You Want to Change Your Medicare Advantage Plan?
You can change your Medicare Advantage plan during any of the annual enrollment periods. Once your new coverage takes effect, your old plan is automatically canceled.
What Are Alternatives to Medicare Advantage?
An MA plan isn’t your only option for Medicare coverage in Virginia. Other options include:
- Virginia Program for All-Inclusive Care for the Elderly (PACE): This program provides community-based medical care if you meet eligibility requirements.5
- Original Medicare: You can stay on Original Medicare if it provides the coverage you need.
- Medicare Supplement: Known as Medigap, these policies are provided by private insurance companies as additional coverage to Original Medicare.
- Medicare Supplement with Part D: You’ll need to purchase a separate prescription drug plan with a Medigap policy, because the policies don’t include Part D coverage.
- Medicare Cost Plans. This plan is available in some parts of Virginia. If you have Original Medicare, it will cover your services even if you go to an out-of-network provider.6
What Are Medicare Resources in Virginia?
- Virginia Insurance Counseling and Assistance Program (VICAP): This program provides free, unbiased counseling to help you navigate your options and enroll in Medicare.7
- State Corporation Commission: This office oversees insurance businesses and offers resources for seniors on Medicare programs in the state.8
- Medical Assistance Programs (Medicaid): Medicaid provides healthcare assistance to those with low income or disability.9
Is a Medicare Advantage plan right for you? Start looking at available plans in your area so you’re ready to sign up when you enroll in Medicare.