Medicare Advantage Plans in Virginia
Fact checked Contributing expert: Roseann Birch; Reviewed by: Leron Moore - Published: November 25, 2020
Medicare Advantage plans are offered by private companies and are a form of Medicare (Part C) where the private company handles all of a Medicare recipient's Part A and Part B benefits. Medical Advantage insurance companies are required by law to provide the same benefits you would receive through original Medicare.
Many of these Medicare Advantage plans in Virginia also cover prescription drug costs. Medicare Advantage plans in Virginia may also offer dental, vision, and hearing services.
Out-of-pocket costs for someone enrolled in a Virginia Medicare Advantage plan depend upon the chosen plan.
- 1 In 2019, there were 1,348 Medicare Advantage plans available in Virginia
- 2 20% of the total Medicare population in Virginia is enrolled in Medicare Advantage plans as of 2018.
- 3 In 2018, Original Medicare spent an average of $9,328 per beneficiary in Virginia, which is 8% lower than the national average.
- 4 Available Medicare Advantage plans range from nine to 48 across Virginia’s 95 counties.
The decision to enroll in a Medicare Advantage plan in Virginia belongs entirely to each Medicare beneficiary. Currently, there are four different types of Medicare Advantage plans from which to choose. In 2019 there were 628 Medical Care Advantage plans in Virginia that received a ranking of four stars or more out of five from the Centers for Medicare and Medicaid Services (CMS) — or over 65% of all the Medicare Advantage plans offered in the state.
Medicare beneficiaries who have had health insurance through an employer will recognize how these plans work in terms of being able to choose doctors who are in-network or out-of-network and whether they provide prescription drug coverage or not.
Medicare Advantage Plans in Virginia
Types of Medicare Advantage Plans
Once a Medicare beneficiary decides to enroll in a Medicare Advantage plan, there are several factors that they should consider before they choose a plan. What are the costs versus the benefits? Do they want a plan that requires a primary care physician? Would they prefer a plan that doesn’t require a referral before they see a specialist?
Virginia’s Medicare Advantage plans provide various options to choose from, although choices are limited by location and the number of Medicare Advantage plan providers in each county.
Health Maintenance Organizations (HMO)
HMO plans generally provide services from providers in the plan’s network. There are exceptions for emergency care and out-of-area urgent care or dialysis. Most HMOs, but not all, provide part D prescription drug coverage. The plan requires participants to choose a primary care physician, and they will also need a referral for any specialist. However, certain preventative healthcare measures, such as a mammogram, are exempt from this requirement.
HMO plans normally have the lowest costs and, in some cases, don’t require a premium. However, plan participants still need to pay Original Medicare’s Part B premium and Part A premium, if applicable.
Preferred Provider Organizations (PPO)
Insurers that offer Medicare PPO plans also work with a network of doctors and hospitals, and participants will pay less if they use these in-network providers. Under a PPO plan, however, you can use doctors from outside the network, but fees are higher.
Because participants have a choice of whether to use an in-network provider, they do not need to choose a primary care physician, nor do they need a referral in most cases. Medicare Advantage plans in Virginia often offer extra benefits not available under Original Medicare, but they will cost extra.
Private Fee-for-Service Plans (PFFS)
Medicare Advantage PFFS plans set limits on fees they will pay hospitals, healthcare providers, and what your share of the cost will be. These are flexible plans. Some PFFS plans contract with a network of providers who will agree to see any of the PFFS plan’s members.
Members can also choose an out-of-network provider if the healthcare provider accepts the plan’s terms on items like fees. Some out-of-network providers won’t accept the plan and can deny you care. However, all doctors and hospitals must treat you during an emergency.
Some PFFS plans cover prescription drugs, but if they don’t, plan members can join a separate Medicare prescription drug plan.
Special Needs Plans (SNP)
These Virginia Medicare Advantage plans are limited to people who have specific diseases or conditions. The SNP plan’s benefits are tailored to provide the best coverage for the specific needs of the member. In most cases, you must use the doctors or hospitals that are in the SNP networks. The only exceptions are emergency or urgent care and if you need out-of-area dialysis for end-stage renal disease (ESRD).
SNP plans require you to choose a primary care doctor and to obtain referrals. All SNPs also provide prescription drug coverage.
In 2019, of the 20% of Medicare beneficiaries in Virginia who chose a Medicare Advantage plans, 89.8% chose an HMO plan, 10.1% chose a local PPO, less than 1% chose a regional PPO, less than 1% chose a PFFS, and less than 1% chose an SNP plan.
Enrollment and Eligibility for Medicare Advantage Plans in Virginia
If a senior wants to receive Medicare coverage through a Medicare Advantage plan in Virginia, they need to meet the following criteria:
- The individual must be 65 years or older or is eligible because of a disability.
- The individual must live in the service area of the plan they want to select.
- The individual must be enrolled in Part A and Part B of Medicare or be eligible to enroll.
- The individual must be a U.S. citizen or permanent resident for at least five years.
- A senior cannot suffer from ESRD and qualify for a Medicare Advantage plan, although an SNP may be an option.
A Virginia senior can enroll in a Medicare Advantage plan at specific times:
- The initial period includes the three months before they turn 65, the month they turn 65, and the three months after they turn 65.
- Yearly enrollment runs from October 15-December 7. During this period, a person who has Original Medicare can switch to a Medicare Advantage plan (and vice versa), or individuals who already have a Medicare Advantage plan can change plans.
- Open enrollment covers January 1-March 31 and affects only Virginia seniors who are currently on Medicare Advantage plans and wish to change plans or who wish to switch back to Original Medicare.
- General enrollment is from April 1-June 30 and affects only individuals who enrolled in Part B for the first time during open enrollment and want to switch to a Medicare Advantage plan.
Prescription Drug Coverage
Prescription drug coverage is available in many Medicare Advantage plans, but coverage differs from plan to plan:
- Some HMO and PPO plans include prescription drug coverage, which may or may not require separate premiums.
- HMOs and PPOs that do not provide drug coverage do not allow their plan participants to obtain separate Medicare prescription drug coverage. If plan participants enroll in a Part D plan, they will lose their membership in a Medicare Advantage plan and revert to Original Medicare coverage
- Some PFFS plans include prescription drug coverage, but if they do not, they will allow their members to participate in a separate Medicare prescription drug plan.
- SNP plans must include prescription drug coverage by law.
The best strategy for eligible seniors is to research each plan to see how they treat prescription drug coverage and then decide which plan works best for their medication requirements.
Medicare Advantage Resources in Virginia
Seniors who are considering enrolling in a Medicare Advantage plan want to pick the best plan for their needs. It can, however, be a confusing process. Unlike Original Medicare, there are many Medicare Advantage plans to choose from, including plans that offer different benefits or plans that are only available depending upon your location. Fortunately, under Medicare Advantage, you have the option of changing plans during specific enrollment periods if your current plan is not providing you the coverage you desire.
There are local and state resources that exist to help seniors who are 65 years of age or older navigate their way through Medicare and Medicare Advantage plans.
The Virginia Insurance Counseling and Assistance Program (VICAP)
VICAP is part of a national network that offers free, confidential, and unbiased counseling for seniors who are on or are about to be on Medicare. VICAP provides counseling on issues like Medicare, Medicare Advantage plans, Medicare Part D, Medigap, and long-term care insurance.
Counselors will also assist seniors with healthcare denials or appeals and identify subsidies for low-income individuals. Counseling is provided at the local Area Agencies on Aging.
Contact information: Website | 800-552-3402
Virginia Bureau of Insurance
The Virginia Bureau of insurance includes several pages on its website that contain information for anyone interested in researching Medical Advantage plans in the state. The site includes information on ways that Medical Advantage insurers can and cannot approach consumers in Virginia.
Since seniors need to be wary of potential scams when selecting a Medicare Advantage plan in Virginia, the Bureau of Insurance website explains signs seniors should look out for to protect themselves.
Contact information: Website | 804-371-9967 or 800-552-7945
Virginia Prescription Drug Assistance Programs
Virginia has several programs for seniors and others designed to assist with the often-high cost of prescription drugs. These programs offer assistance for seniors on Medicare and non-Medicare individuals, including the Virginia Prescription Drug Card, which provides cost savings of up to 30% on both generic and brand drugs to every resident of the state of Virginia.
Contact information: Website | (Virginia Drug Card) 866-413-9778
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Roseann Birch, Medicare Consultant
With experience in the insurance field since 1986, Roseann Birch is a seasoned Medicare consultant who is passionate in educating and guiding seniors through their Medicare and Medicare Advantage journey.
Leron Moore, Medicare Consultant
With over 10 years of experience in the Medicare industry, Leron Moore has dedicated his career to effecting change, educating, informing, and resolving issues for Medicare patients and their families.