If you’re signing up for Medicare, the government-run healthcare program made up of Part A (hospital insurance) and Part B (outpatient insurance), you might be wondering if it offers enough coverage for you. Medicare Part A and B, or Original Medicare, won’t cover all of your medical expenses. It doesn’t include coverage for prescription drugs and doesn’t limit your annual out-of-pocket costs.
Medicare Advantage (MA) plans, or Medicare Part C, might be one option for you. These plans are provided by private insurance companies and offer the basic coverage of Original Medicare. Most MA plans also cover prescription drugs and cap your annual out-of-pocket costs.
What You Need to Know
A Medicare Advantage plan provides the same basic coverage as Original Medicare.
Most MA plans in West Virginia have prescription drug coverage.
Many plans include additional benefits, like gym membership reimbursement.
What Types of Medicare Advantage Plans Are Available?
Many Medicare Advantage plans in West Virginia work with a network of doctors and healthcare facilities to make services more affordable. Popular types of plans include:
- Health Maintenance Organization (HMO): You’ll need to designate a primary care physician (PCP) for regular care and referrals to specialists. Except for certain emergencies, you’ll have to visit an in-network doctor or potentially pay more out-of-pocket for your care.1
- Preferred Provider Organization (PPO): You won’t need to designate a PCP, but you’ll still probably pay less out-of-pocket if you visit an in-network doctor.
- Special Needs Plans (SNP): You can join these plans if you have certain health conditions.2
- Chronic Condition SNP (C-SNP): These plans are designed to help you manage chronic conditions, such as cardiovascular disease or diabetes.
- Institutional SNP (I-SNP): You can join these plans if you live in a nursing home or require in-home nursing care.
- Dual-Eligible SNP (D-SNP): You’re eligible for these plans if you qualify for both Medicare and Medicaid.
- Private Fee-for-Service (PFFS): Your plan provider will determine how much to pay doctors for services. It also decides how much you’ll pay for services when you receive care. You won’t need to choose a PCP.
- Medicare Medical Savings Accounts (MSA): This high-deductible health insurance plan uses an MSA to pay for out-of-pocket medical expenses.
What Are Prescription Drug Options with Medicare Advantage?
Original Medicare doesn’t cover prescription drugs. You’ll have to purchase an additional Medicare Part D plan for coverage. Most Medicare Advantage plans in West Virginia, however, do include coverage for prescription medications.
You can make sure a plan covers your prescriptions by looking at the plan’s drug formulary, or list of covered medications.
How Do You Choose Medicare Advantage Plans?
Before choosing a Medicare Advantage plan in West Virginia, be sure to weigh the costs and benefits, such as:
- Premiums: This is the price you’ll pay for your plan each month, in addition to the Medicare Part B premium ($148.50 for most people in 2021). You may be eligible for a zero-premium plan, but other costs, like your deductible, might be more expensive.
- Other Costs
- Deductible: This is the annual amount you’ll need to cover out-of-pocket before your plan starts paying for services.
- Coinsurance: Your portion of the cost for a service. It’s usually a percentage of the total cost.
- Copay: A fixed price you’ll pay for specific medical care.
- Out-of-Pocket Maximum: The annual limit on your out-of-pocket expenses, usually excluding premiums.
- Plan Benefits
- Vision: Covers services such as frames or eye exams.
- Dental: Includes coverage for teeth cleaning and checkups.
- Telehealth: Covers remote health services such as video office visits or phone consultations.
- Additional Perks: Most Medicare Advantage plans in West Virginia also offer benefits like transportation services or fitness classes.
Eligibility for Medicare Advantage
You’re eligible for Medicare Advantage as soon as you’re eligible for Original Medicare,
How to Save Money
You’ll save money on a Medicare Advantage plan by going to in-network providers.
When and How to Enroll in Medicare Advantage?
You can join a Medicare Advantage plan after enrolling in Original Medicare. You’re first eligible to enroll during your Initial Enrollment Period, or Open Enrollment Period (OEP), which starts three months before you turn 65 and ends three months after you turn 65.
If you miss your Initial Enrollment Period, you can still enroll in Original Medicare during the General Enrollment Period between January 1 and March 31 each year. You may have to pay a late penalty on your Medicare premiums if you enroll outside of your OEP.
Signing up for Original Medicare is easy. You can enroll through the Social Security Administration online, in person or over the phone. After joining Original Medicare, you can pick your Medicare Advantage plan.
Other enrollment periods for Medicare Advantage in West Virginia include:3
- Initial Enrollment Period: Sign up for an MA plan when you enroll in Original Medicare.
- Medicare Annual Election Period: Choose an MA plan during annual open enrollment between October 15 and December 7.
- Medicare Advantage Open Enrollment Period: Change your MA plan or go back to Original Medicare annually from January 1 to March 31.
- Special Enrollment Period: Certain circumstances may make you eligible for a special enrollment period, including:
- You’re moving outside of your current plan’s service area.
- You receive coverage from a union or employer.
- You’re about to lose your coverage, such as becoming ineligible for Medicaid.
- Medicare is terminating your plan.
- You have a special health condition that requires an SNP.
Who Has Signed Up for Medicare Advantage in West Virginia?
Nearly 170,000 Medicare-eligible seniors have signed up for Medicare Advantage plans, which is about 35% of Medicare-eligible beneficiaries.
How Much Do Medicare Advantage Plans Cost in West Virginia?
The cost of Medicare Advantage plans in West Virginia can vary due to several factors. Where you live within the state, for example, could affect what’s available to you. The average cost of an MA plan in West Virginia in 2021 is $32.30.4
You can expect to pay between $0 and $167 in monthly premiums in Charlestown and Morgantown.5 Remember that other out-of-pocket costs, such as your deductible or copay, could change how much your MA plan costs per month.
What If You Want to Change Your Medicare Advantage Plan?
If you don’t qualify for a special enrollment period, you can change your MA plan during any of the annual enrollment periods. Your old plan automatically terminates when your new coverage starts.
What Are Alternatives to Medicare Advantage?
There are other coverage options outside of Medicare Advantage plans in West Virginia, including:
- Original Medicare: You can keep Medicare Part A and B if the coverage is right for you.
- Medicare Supplement: These private insurance policies, also called Medigap, give you additional coverage to Original Medicare.
- Medicare Supplement with Part D: Medigap policies don’t include prescription drug coverage, so you’ll need to purchase a separate prescription drug plan.
What Are Medicare Resources in West Virginia?
- West Virginia State Health Insurance Assistance Program (SHIP): SHIP provides free, unbiased counseling to help answer your questions and get you enrolled in Medicare.6
- Offices of the Insurance Commissioner: The West Virginia state insurance department has resources to help you understand Medicare and contact information for insurance consumer services in the state.7
- West Virginia State Medicaid Plan: The Medicaid program provides health coverage to eligible seniors and those with disabilities.8
Carefully consider your healthcare options, including Medicare Advantage plans in West Virginia, before you’re eligible for Medicare. This way, you’ll be ready to sign up for the program that’s right for you.