Medicare Advantage Plans in West Virginia

Medicare Advantage plans are an alternative to Original Medicare, offered by private insurance companies approved by Medicare. These plans include Part A (hospital insurance) and Part B (medical insurance), and most also include Part D (prescription drug coverage). Many plans offer added benefits like routine 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, but some qualify earlier due to disability or conditions like ALS or ESRD. There are key enrollment periods: Initial, General, and Special Enrollment. Missing these periods or not qualifying for premium-free coverage may result in penalties.

What Types of Medicare Advantage Plans Are Available in West Virginia?

West Virginia offers the following MA plan types:

• Health Maintenance Organizations (HMOs): Require in-network care; referrals needed for specialists.
• Preferred Provider Organizations (PPOs): Allow out-of-network care at higher costs; typically no referrals needed.
• Private Fee-for-Service (PFFS) Plans: Any provider who accepts plan terms can be used; some plans have networks.
• Special Needs Plans (SNPs):
  • C-SNPs: For chronic conditions like diabetes, HIV/AIDS, or heart disease.
  • I-SNPs: For individuals in institutions or requiring nursing care.
  • D-SNPs: Dual Eligible Special Needs Plans for people who qualify for both Medicare and Medicaid. They offer extra benefits like drug coverage, dental, and care coordination.
• Medical Savings Accounts (MSAs): Combine a high-deductible plan with a medical savings account funded by your insurer.

What Are Your Prescription Drug Options with Medicare Advantage?

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

• Enroll in a separate Part D plan (only allowed for some plans).
• Face a late enrollment penalty if you delay getting prescription coverage without having creditable coverage.

How Do You Choose a Medicare Advantage Plan?

Understand Medicare Advantage costs before choosing a plan:

• Premiums: Many MA plans have $0 premiums; others may charge a monthly fee.
• Deductibles, Coinsurance & Copays: Understand what you’ll pay out of pocket for medical services.
• Out-of-Pocket Maximums: This cap limits how much you’ll spend per year on covered services.
• Extra Benefits: Some plans offer dental, vision, hearing, telehealth, fitness programs, and over-the-counter allowances.

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

You can enroll in Medicare during specific enrollment periods:

• Initial Enrollment: Begins 3 months before your 65th birthday month and ends 3 months after.
• 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 during this period.
• Medicare Advantage Open Enrollment (Jan 1–Mar 31): Switch or return to Original Medicare if already in an MA plan.
• Special Enrollment Periods: Triggered by life events such as:
  • Moving outside your plan’s area
  • Losing employer/union coverage
  • Plan termination
  • Qualifying health conditions

What If You Want to Change Your Medicare Advantage Plan?

You can switch plans during:

• 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 Medicare Advantage (MA) plans using a 5-star quality rating system. These ratings help consumers compare the performance of different plans based on a standardized set of measures.

Here’s a breakdown of how the CMS star ratings system works:

• 1 star: Poor performance
• 2 stars: Below average
• 3 stars: Average
• 4 stars: Above average
• 5 stars: Excellent

These ratings are updated annually and reflect data collected from Medicare Advantage (Part C) and Medicare Advantage Prescription Drug Plans (Part D).

What Are Medicare Resources in West Virginia?

West Virginia offers several helpful programs:

• West Virginia SHIP Program: Provides free counseling on Medicare coverage.
• West Virginia SMP Program: Educates beneficiaries on how to avoid healthcare fraud.
• State Insurance Department: Handles complaints and coverage issues.
• For low-income residents, West Virginia Medicaid may assist with medical costs. Visit dhhr.wv.gov or call 1-877-716-1212 for details. Learn more about the differences between Medicare and Medicaid.

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

Medicare Supplement Plans, or Medigap, are standardized policies sold by private insurers to cover out-of-pocket costs from Original Medicare, such as deductibles, copayments, and coinsurance.

• You must be enrolled in Medicare Parts A and B to purchase a plan.
• The best time to enroll is during the six-month Medigap Open Enrollment Period, which starts when you enroll in Medicare Part B. During this time, coverage is guaranteed regardless of health. After that, you may need to pass medical underwriting.
• Medigap plans don’t cover prescription drugs, so you’ll need a separate Part D plan.
• There are 10 standardized plans, with Plans F, G, and N being the most popular. Medicare Supplement Plan G had the highest enrollment in 2023, and Plans G and N are the fastest-growing.
• Due to Medicare changes in 2020, Plan F is no longer available to newly eligible beneficiaries. Premiums vary by plan and location, but all offer predictable costs, no referrals, and nationwide coverage with Medicare providers.

Next Steps

If a Medicare Advantage plan in West Virginia is right for you, compare available plans in your area. Review provider networks, out-of-pocket costs, and extra benefits—then be ready to enroll when eligible.