Medicare Advantage Plans in West Virginia

Fact Checked
Updated: June 30, 2021

All Americans aged 65 or older and those who are disabled are eligible for Medicare. Original Medicare, which is managed by the federal government, is composed of Part A and Part B, which together include items, such as hospitalization, doctors’ visits and mental health care. Medicare Advantage Plans are offered by private health insurance companies approved by Medicare and must provide the same coverage as Original Medicare Parts A and B. These plans usually include additional benefits, such as vision, dental, hearing, and fitness programs, and many Medicare Advantage Plans also include prescription drug coverage.

  • In 2019, there were 33 Medicare Advantage Plans available in West Virginia
  • 26% of the total Medicare population in West Virginia is enrolled in Medicare Advantage Plans as of 2018.
  • In 2018, Original Medicare spent an average of $9,852 per beneficiary in West Virginia which is 2% lower than the national average.
  • Available Medicare Advantage Plans range from 17 to 28 across West Virginia’s 55 counties.

West Virginia seniors who want to enroll in Medicare Advantage have a broad selection of plans to choose from. Some plans are restrictive, while others provide more options for where you can seek care. Medicare Advantage Plans have different copays, premiums, and deductibles, and the plans you’re able to select will depend on where you live and your health insurance provider.

Medicare Advantage Plans In West Virginia

Types of Medicare Advantage Plans

West Virginia’s Medicare Advantage program has four types of Medicare Advantage Plans, including HMOs, PPOs, PFFSs, and SNPs. Some plans are less expensive but more restrictive, while others are tailored for specific diseases and situations. Plans that have more flexibility tend to be more expensive, and some plan types aren’t accepted by all health care providers. All Medicare Advantage Plans offer the same coverage as Original Medicare Parts A and B at a minimum.

Health Maintenance Organizations (HMO)

You may be familiar with Medicare Advantage HMO plans because these plans operate like a regular HMO. Health Maintenance Organizations are a little less expensive than other plans, but you’re restricted to using in-network health care providers, and you must select a primary care physician and obtain a referral to see a specialist. These plans also offer vision, dental, hearing, and fitness programs, and many also provide prescription drug coverage.

Preferred Provider Organizations (PPO)

PPOs tend to cost more than HMOs. You have the option to use out-of-network health care providers, but you can keep your costs down by seeking care within the network. With these plans, you don’t need to name a primary care physician or obtain a referral to see a specialist. Medicare Advantage PPOs offer hearing, vision, dental, and fitness programs. Some of these plans also offer prescription drug coverage, but not all of them do.

Private Fee-For-Service Plan (PFFS)

If you’re looking for flexibility in your health care, you may want to consider a PFFS plan. Under a PFFS plan, the insurance company decides how much it will pay for your care and how much you’ll contribute. You can use any provider who accepts your plan. While all health care providers must accept your plan in an emergency, some might not under normal circumstances. Many PFFS plans provide prescription drug coverage.

Special Needs Plan (SNP)

SNPs are designed for residents of nursing homes, those who qualify for both Medicare and Medicaid, and those with chronic diseases, such as end-stage renal disease (ESRD) or AIDS. The benefits included with these plans are tailored to the medical needs of the groups served. You must use in-network providers, obtain referrals to see specialists, and name a primary care physician. SNPs are legally required to provide prescription drug coverage.

Enrollment and eligibility for Medicare Advantage Plans in West Virginia

Medicare Advantage Eligibility

  • You must be a U.S. citizen or a permanent resident for the past five years
  • You must be aged 65 or older or younger and disabled
  • You must be enrolled in Original Medicare’s Parts A and B but not in Medicare Supplement Insurance (Medigap) because you can’t be enrolled in Medigap and Medicare Advantage at the same time.
  • You must live in the service area of the plan you select

Enrolling in Medicare Advantage

  • Initial enrollment starts three months before you turn 65, includes the month of your birthday and continues for three months after your 65th birthday. You can enroll in Original Medicare or a Medicare Advantage Plan during this seven-month period.
  • Open Enrollment starts on October 15th and runs until December 7th. You can switch from Original Medicare to a Medicare Advantage Plan, return to Original Medicare, or switch between Medicare Advantage Plans during this period.
  • Medicare Advantage Open Enrollment runs from January 1 to March 31. You can switch between Medicare Advantage Plans or return to Original Medicare during this period. However, if you’re currently enrolled in Original Medicare, you can’t switch to a Medicare Advantage Plan. If you’ve never registered for Part B, you can do so during this period, and then you can select a Medicare Advantage Plan between April 1 and June 30, with coverage starting on July 1.

In certain circumstances, you may qualify for a Special Enrollment period. Qualifying circumstances include moving out of your county, qualifying for an SNP, or losing your current policy.

Prescription drug coverage

Many HMO and PPO plans include prescription drug coverage. If yours doesn’t, you can’t purchase a separate Part D plan. If you do, you’ll be kicked out of your Medicare Advantage Plan and returned to Original Medicare. Many PFFS plans include prescription drug coverage, but if yours doesn’t, you can purchase a Medicare Part D plan. All SNP plans are legally required to provide prescription drug coverage to their members.

Medicare Advantage Resources in West Virginia

If your initial enrollment period is approaching, you may be confused about whether to enroll in Original Medicare or a Medicare Advantage Plan. Those who are already enrolled may start to wonder if they should stay with their current Medicare Advantage Plan, switch to a different plan, or return to Original Medicare. Fortunately, many organizations in West Virginia have trained volunteers who can provide free, unbiased, and confidential answers to your questions.

Area Agencies on Aging (AAA) 

West Virginia’s four Area Agencies on Aging work with local senior centers to provide information, resources, and programs for seniors across the state. The AAA provides nutritious food if you’re in need or housebound, places where you can enjoy congregate meals and socialization with other seniors, and transportation to your medical appointments. Trained counselors can also answer your questions about Medicare, Medicaid, and Medicare Advantage.

Contact Information: Website | (304) 558-3317

West Virginia State Health Insurance Assistance Programs (SHIP)

The West Virginia SHIP program can provide you, your family, or your caregivers with free, unbiased, and confidential information about Medicare, Medicare Advantage, long-term care insurance plans, as well as assistance with Medicare costs. None of the program’s trained volunteer counselors work for a health insurance company, and they’ll never try to sell you a plan. You can speak with a SHIP counselor over the phone or in person.

Contact Information: Website | 877-987-4463

State Medicare Patrol (SMP)

Medicare fraud is a serious matter in the United States. The State Medicare Patrol can show you how to detect and report Medicare fraud and abuse. You’ll learn how to spot errors in your Medicaid billing and how to recognize Medicare scams. The SMP regularly holds community outreach programs, but you can also call your local SMP branch to have one of its volunteer counselors work with you in person.

Contact Information: Website | 855-254-1720

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