- In 2019, there were 78 Medicare Advantage Plans available in Virginia.
- 18% of the total Medicare population in Virginia is enrolled in Medicare Advantage Plans as of 2018.
- In 2018, Original Medicare spent an average of $9,328 per beneficiary in Virginia, which is 8% lower than the national average.
- Available Medicare Advantage Plans range from nine to 48 across Virginia’s 95 counties.
Depending on where you live, you may have several Medicare Advantage options to choose from. Like health insurance plans that are employer-subsidized or purchased on the federal Marketplace, Medicare Advantage Plans may have in-network providers, monthly premiums, and annual deductibles. Some plans include prescription drug coverage, discounts on fitness and wellness programs, and vision and dental coverage. Your health needs and budget will determine which plan type is right for you.
Medicare Advantage Plans in Virginia
Types of Medicare Advantage Plans
Virginia’s Medicare Advantage program has a broad array of options for retirees, including HMOs, PPOs, PFFS plans, and SNPs. With some plans, you’re required to obtain health services from in-network providers. Other plans have coverage for services that you get from doctors, specialists, and hospitals outside of your plan’s network, but you generally pay a bigger portion of the costs you incur. Regardless of the plan type you choose, all plans provide at least as much coverage as Original Medicare.
Health Maintenance Organizations (HMO)
With an HMO plan, you access your Medicare benefits through your plan’s network of hospitals and physicians. You’re generally required to choose a primary care doctor who provides the majority of your health services and refers you to specialists in your plan’s network for services outside of their scope of care. In most cases, HMOs are the most cost-effective options, but these plans have little flexibility. If you get health care services outside of your plan’s network, you generally pay the entire bill unless it was an emergency situation.
Preferred Provider Organizations (PPO)
Like HMO plans, PPO plans have in-network hospitals, doctors, and specialists that you receive care services from. However, these plans provide a greater degree of flexibility by covering services you get from providers outside of the network, although you generally pay a higher portion of health care costs. In most cases, you don’t have to choose a primary care provider, and the networks tend to be much larger than HMO networks.
Private Fee-For-Service Plans (PFFS)
PFFS plans aren’t as common as HMO and PPO plans, and only a limited number are available in Virginia. Each PFFS plan has its own terms and conditions for how much the plan pays out for services and how much you pay. The plan can be used at any provider who agrees to the plan’s payment terms. Some plans have networks of health care providers who agree to always accept the plan’s terms, and providers who aren’t part of the plan’s network can opt to accept or decline the coverage on a case-by-case basis.
Special Needs Plans (SNP)
SNPs are tailored to meet the needs of beneficiaries with specific conditions or situations. For example, some plans are for those who are dually eligible for Medicare and Medicaid or who live in a nursing home, while others are for those with chronic conditions, such as diabetes or autoimmune disorders. Because SNPs provide special services, you’re limited to receiving care from your plan’s network, meaning that you may be required to choose a different primary care doctor. Depending on your plan’s terms, you may need referrals to see specialists.
Enrollment and eligibility for Medicare Advantage Plans in Virginia
Medicare Advantage Plans are available to those aged 65 and over, although younger individuals may qualify due to certain illnesses or disabilities. You must be enrolled in or eligible for Original Medicare Parts A and B but not enrolled in a Medigap Plan, and you must live in your plan’s service area.
You can only join or switch Medicare Advantage Plans during certain periods throughout the year. These include:
- Initial enrollment period: This period opens when you first become eligible for Medicare and begins three months before you turn 65, includes your birth month, and continues for three months after your birthday.
- Open enrollment period: This period spans from October 15 to December 7. At this time, you can join, change, or drop a Medicare Advantage Plan or switch to Original Medicare. Any changes you make take effect on January 1 of the following year.
- Medicare Advantage enrollment period: During this period, which runs from January 1 through March 31, you can switch to a different Medicare Advantage Plan or switch back to Original Medicare.
Certain life events trigger enrollment periods outside of these regularly scheduled periods, such as losing your plan due to moving outside of your plan’s service area, your plan changing its contract with Medicare, or becoming eligible for Medicaid.
Prescription drug coverage
One of the biggest benefits of Medicare Advantage is that most plans include prescription drug coverage, which isn’t available under Original Medicare. HMO and PPO plans usually have this coverage included, but if not, you aren’t permitted to add this coverage via a Part D plan. PFFS plans may have this coverage, but you can add prescription drug coverage if yours doesn’t. SNPs always cover prescription drugs.
Medicare Advantage Resources in Virginia
In Virginia, seniors have access to the VA Insurance Counseling & Assistance Program. This program provides free, unbiased options counseling for Medicare-eligible seniors with counselors who answer questions about the state’s CCC Plus waiver program, Medicare and Medicare Advantage benefits, long-term care insurance, and prescription drug coverage. This counseling is administered at different locations throughout the state.
Area Agencies on Aging
Virginia has 22 Area Agencies on Aging that administer federally-funded services at the local level. Through these agencies, residents can schedule appointments with VICAP counselors who can help them sign up for Medicare, understand their plan’s benefits, and understand and settle medical bills. VICAP services may be available over the phone or in-person at senior centers, residential care facilities, and health care centers throughout the state. In addition to providing VICAP services, the local AAA can connect seniors with nutrition programs, health services, transportation, and personal care services.
Contact Information: Website | 800-552-3402
Office for Aging Services
The state’s Office for Aging Services provides information on health insurance for residents. Through this office, seniors obtain information about Medicare and Medicare Advantage programs, including more in-depth information about the different types of Medicare Advantage Plans. The office can also help seniors find their local long-term care ombudsman; disability, aging, and veteran resources; and local financial assistance programs.
Contact Information: Website | 804-662-9333
State Corporation Commission
The State Corporation Commission regulates insurance in Virginia. It operates the state’s Health Benefit Exchange and provides information on long-term care insurance, the managed care ombudsman, and enrollment deadlines. It also maintains a database of senior resources to help them find VICAP counselors, continuing care services, and information on senior health insurance plans.
Contact Information: Website | 804-371-9967
Learn More from Our Sources
- Medicare Plans | Medicare Care Advantage Plans (Part C) | Last accessed June 2021
- Medicare | Medicare Advantage Plans | Last accessed June 2021
- Medicare Plans | Medicare Advantage HMO Plans | Last accessed June 2021 | Last accessed June 2021
- Medicare Plans | Medicare Advantage PPO Plans | Last accessed June 2021
- Medicare | Private Fee-for-Service Plans | Last accessed June 2021
- Medicare Plans | Medicare SNP Plans | Last accessed June 2021
- HHS | Who Is Eligible for Medicare? | Last accessed June 2021
- Medicare | Joining a Health or Drug Plan | Last accessed June 2021
- Medicare | Special Circumstances | Last accessed June 2021
- Medicare | Drug Coverage | Last accessed June 2021